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r <br /> 8-17-1999 1 :59PM F ��y P. 2 <br /> 8 1999 <br /> WELL PERMIT APPLICATION Fb M UNIT IV <br /> U �_ JICES <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH`8tRV' lI' <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (2091468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ct and/gr install the work described. This application is made <br /> Application is hereby made to San Joaquin County for a permit to construin compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental a Health Division. <br /> 2(OJ�Sp S•3f )?--D Cross Street City Tom'-c-� Zip Parcel# <br /> WELL Location n � A <br /> PROPERTY Owner A���C� � �o Address 6-, 5 P-, �C�ty �V , Zip 95371v Phone# <br /> v� 5 <br /> JC, / e City A�P l Zi�W1 6-b Lic# Phone# <br /> C-57 Contractor t20 �EpSC'IGIUC.i;-S Address 13r�}9�'�IU`e,�r�L <br /> ttVyCity <br /> Consultant f Sub Contractor � t &>r F e-ATL0rN Address 4tP5 1` 0PTCNtCA[OU:�f� Lic# Phone#92528 9�9t <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type below <br /> NEW WELL/BORING COP, G=OPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 D OVER-BORE <br /> 0 SOIL BORING# PRESSURE GROU- <br /> WELL# <br /> 'Other: <br /> COMMENTS' <br /> TYPE OF WELL IN57ALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE 1.5' MULTIPLE CASINGS?0 YES ULNO WELL CASING DIA:_ <br /> D MONITORING <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N/A TYPE OCASING: STEEL <br /> REM ETYPE TO BE USED: DR <br /> 0 AUGERSDHOS <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE ) PUSH POINT GROUT SEAL PUMPED: JJ7Yes No (NOTE:BMAXIMUM TRAFFIC BOX oLLDEPTH IS D STOVE PPE t <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 1 U D <br /> ,).� CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> ;OTHER: C-t I 0 OTHER <br /> GOMMENTS: <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 RL <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the we <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APP <br /> IC ANT M ST LL 48 HRS IN ADVANCE <br /> �FOR <br /> � ALLr�R ,QUIRED INSPEC IONS. <br /> Title r �1 �ft 1�l`1 L Date (b <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> �V Q� Date Issued l%U �� <br /> Application Accepted ByArea Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> EACCOUNTING ONLY: AID# <br /> ES FEE INFO AMOUNT REMITTED CH K ASHRECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INV(q.or62� 7� ' <br /> C-57 LICENSED CONTRACTOR:MUST SIGN LICENSE&WORKERS'=COMPENSATION DECLAR.ATIO] <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />