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WE• PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVE[ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 16 1999 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> I Assessor's <br /> WELL Location //'� Al. 1I pjh,fn b St Cross Street _City slip-47i 7.OZ Parcel# <br /> PROPERTY Owner�JS&n f (Oq' dy Address A0&2)- 1 z6V City "3,,,,��Zip Ll Phone# <br /> C-57 Contractor( CISCA// _Address S 7- OA C r 0 City PA-d6 _uc�p J5�77N Lic#7f 7S/U Phone#C//!6 3 Sf 1169 <br /> Consultant/S b Contractor brOVNd 7iiV Address 1714/OWAI Sk City�9cdt' Lic# Phone# g.38-�$f� <br /> GIS Coordinates:X , Y .Township Range Section <br /> WORK TO BE PERFORMED <br /> 64 <br /> W WE !BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 0-tlOELL# YnwL rh rte tures S �4 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS /r <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE rr MULTIPLE CASINGS? 0 n+V WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSCN 40 TYPE OF CASING: 0 STEEL 0'15VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B-I(UGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE--:``MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 32 � tfnOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of he work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hiring - <br /> contracting signature certifies the following: "/certify that in the performance of the work for which this permit is issued, I shall employ persons subgjto <br /> WORKERS'COMPENSATION Laws of California." � o <br /> +TA TMUSTCALL48WO k(ING HRS IN ADVANCEFOR ALLREQUIRED INSPECTIONSSigned x Title(oCG> /S/ DateSEEMAPIN UNIT IV WORK PLAN DATED: v <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 124 1 /OaArea <br /> Grout Inspection By wnn..r•e� Dat , Z o e Final Inspection By� �Date./ / <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 So �6�t o13 01031 r2 , baK <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />