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1-14-2000 2 45PM FROM <br />WELL PERMIT APPLICATION FORM <br />• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E Weber, Third Floor, Stockton. CA., 96202 <br />(209) 468-3449 <br />UNIT IV <br />P 2 <br />NOWREF NDABLE PERM T EXPIRES 1 YEAR FROM DATE ISSUED <br />Appiicadon is nereby made to San Joaquin County for a permit to construct and/or install the work descnbed This appli:ation is n'tade in oornphance with <br />San Joagwn County Developmertt yTitlle Chapter 9 1115 3 and the Standards of San Joaquin County Public Health Services, Envir� es �r s ea'th Division <br />WELL Location <br />301 I<,eWeViv.euA L—L Croce Strast S L� A''--' City �•e� � Zip Parcel#�T 1-° t <br />PROPERTY Owner P.ut'D�c1 Address Pa ebGood Clty��ZiP 114hones' <br />C57 Contractor <br />{i 4W Oflklt+r:� r 1V%r-j.;_Address 0. &A ( City U[ Zip q`���Lic# 4 Phoneik' �"3'7�-2815 <br />36�`=u,73 <br />dressConsultantI Sub ContracC Phone#4f6�b31-13n4 <br />015 Coordinates X Y Township Range Section <br />WORK LQ gg PEMO[ILE—D <br />NEW WELL BORING ( CPT, GEOPROBc HYDROPUNCH HAND -AUGER OTHER') a DESTRUCTION (choose type below) <br />U SOIL BORING it (j OVER -BORE <br />a WELL # w — CZ PRESSURE GROUT <br />*Other C rt well I[- 11-49 <br />COMMENTS As 5 <br />(KMONITORING to:HOLLOW STEM <br />a EXTRACTION D AIR HAMMERIORIVEN <br />a VAPOR 0 MUD ROTARY <br />p AIR SPARGE 0 PUSH POINT <br />p SOIL BORING n HAND AUGER <br />p OTHER. -----------I1 OTHER <br />CONSTRUCTION SPECIFICAIJUN22 n <br />DIA OF BOREHOLE R MULTIPLE CASINGS-, 0 YES 15NO WELL CASING DIA <br />CASING THICKNESS SC d TYPE OF CASING a STEEL �IIC OTHER <br />DEPTH OF GROUT SEAL,,, S I _Ti TYPE TO SE USED WUGERS OHOSE <br />GROUT SEAL PUMPED XYes p No (NOTE MAXIMUM FREE -FALL DEPTH 15 30) <br />APPROX BORING DEPTH --1 i *Oli TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (of YES list specifications neref <br />COMMENTS <br />NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby ceRif}r that !have prepared this application and that the work will be done In accordance with San Joaquin County Ordinences, State Laws, and Rules <br />and hereby <br />c r`,o t a the San Joaquin GaLnty Homeowner or 6censad agents signature certifles the folloniing "t certify that in the performance of the work <br />for Regu this s of the Is issued, I shell not employ persons subject to WORKERS' COMPENSATION Laws of Catff=12 " Contractor's hiring or SLb- <br />=ntractlrtp signai c0r{fies the following I aer* that In the pdnb mance of the work for which this permit rs issLod, t shall employ persons sabJec; Co <br />WORKERS COMPENSATION Laws of Califonria <br />ArLIICANT MUST CALL 48 WORKING HRS IN AD/0—VANIOE F.OR ALL REQUIRED INSFECTIONS. <br />i/ Ti 170 [a4 Ji ---Date I '. `] _ 7C <br />Sigled <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY L ap 00 <br />�t _ <br />Application Accepted By Date issued �,f Area/—Pp T <br />Grout Inspection By <br />Date Final Inspectier By Gate— � ---- <br />Destruc'Icn inspection Ry <br />COMMENTS 1 CONDITIONS <br />ACCOUNTING ONLY <br />PE CODES ' FEE INFO <br />Date <br />AID# <br />AMOUNT REMITTED I CHECK* <br />RECD BY I DATE <br />PERMIT ISERV110E REQUEST # I INVOICE <br />•*C6SED G4NTRAC.X9X S -r S1GI;'x. (CF— sk&vtO ry 51 COMPENSAII:ON MCLAItATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />