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GSrs rr zcud 14: .31 �eay4b83433 FIFTH FLOUR <br /> i <br /> - WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (249) 468-3449 a <br /> NON-REFUNDABLE PERMIT EXPIRI=8 1 YEAR FROM DATE ISSUED <br /> 1 Application{s hereby made to San Joaquin County for a permit to construct andior install the work described. This application is made in compliance with <br /> San Joaquin County Aevelopment Tide,Chapter 9-1115.3 and the Standards of Sac Joaquin County Public Health Services, Environmental Health Division, <br /> /, j' Assessor's <br /> VyELL Location <br /> 3730 A,A ,41 AilL f'p reo�`�_Cross Stlnf'o`rec (�� City urU^ Zip Paroelu <br /> - <br /> p/ it <br /> PROPERTY Owner `--"I+lvi�r`r r"r"r✓'�Address 5�'"r City l Zip phone# <br /> C-57 Contractor_ r^c G 9 'a nl«^/ Address�5� !71?,�Q re C City i?- Zip L{c# �SC6S Phone# t�zS 713-s�i ov <br /> Consultant ISub CD1171 tOr �2- S Address2S2o (/e �1e clt1� Itty Sat Lidf Phone# - 3Yb <br /> Gly Coordinates: ,Y .Township 4 Mange Section <br /> WORK TO BE PERFORMED ' <br /> i; <br /> ;WEW WELL I BORING(CPT,GEOPROeE,HYD PUNC , ND-AUGER,OTHER`) 3 Q DESTRUCTION(choose type below) <br /> VSOIL BORING# Q Il OVER-BORE <br /> I]WELL d PRESSURE GROUT <br /> •Other. <br /> COMMENTS: li <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ;I <br /> i3 <br /> i 0 MONITORING *HOLLOW STEM DIA.OF BOREKOLE S ` MULTIPLE CASINGS?a YES JYNO WELL CASING DW <br /> EXTRACTION p AIR HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: p STEEL J PVC D OI <br /> p VAPOR a MUD ROTARY DEPTH.OI=GROUT SEAL I� TREMIE TYPE TO BE USED: 0 AUGERS pHOSE <br /> R AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: n-Yes a No (NOTE: MAXIMUMFREE-FAL!`DEPTH I5 30'} <br /> >WSOIL BORING p HAND AUGER APPROX.BORING DEPTH li 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> ti p•r{.{gR;�p OTHEI' if YES,lists <br /> R CONDUCTOR CASINO PROPOSED? ( paciflcMions here): <br /> li <br /> COMMENTS: i <br /> I� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that t 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 Joaquln County. Homeowner or licensed agents slgnalurc ce tl}Ies the following: '7 certify that in the performance offhe wal <br /> W which this permit is issued I shall not employ persons subject to WORKERS'COMPENSATION Laws of Cafftiomia:' Contractoes hiring or sub- <br /> contracting signature Certifies the following:7 certify that in the performance of the work for which ihis parmlt is issued,I shall employ parsons subject to <br /> . i ._ hfomla.° !1 ,_ -r In.. <br /> N Laws of Ca.,.. . .. <br /> WORKERS,COMPENSATION ► ' 1N AD Fifa 4 t 0 °�� <br /> GALL ITk1liT�1N . .E TDR:.:aa1�� al _..... � IREI]� 5: �: Si <br /> Signed x Title/company— <br /> to <br /> itlelGompany C G v, <br /> �• t<< C K Date �lr' 1O o {w� t J cruel P <br /> Print Name rysngyu <br /> O <br /> 31 <br /> DEPARTMENT USC:ONLY 3 <br /> ria 1 . <br /> Application Acrspled 6y [late lssu <br /> Grout Inspection ByDate Zo u rhinal Inspladion By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS: Ij <br /> I� <br /> ACCOUNTIN43 ONLY: AID# CAM <br /> „ f <br /> JPEl FEE INF0 AMOUNT REMITTEt] CHECK# RECD BY DATEIL PERMIT!SERVICE REQUEST# INVOICE <br /> �o 3 _3 y <br /> 1/18/2000 <br /> ! 7tj' _ L�'D L� �Le-� C�C/1//1`-etio L <br />