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J YJ-i I J.JJ `J LJI'YI I i rlVi <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION RF <br /> 304 E.Weber,Third Floor,STOCKTON,CA 95202 F-- i x(209)468-3450 , <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATUAFrUV4 <br /> 1997 <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 /> Assessor's <br /> WELL Location d 10O S. RAn!' CA RoAh Cross Street City TRAcy Parcel# 25Z-1S0-0k <br /> PROPERTY Owner's Name CAL-tFoRNM kblT% W WAL00> CO.Address I}0 N.FAst ST, SurrTF, 1✓00DUuNA I CA Phone# 530-���_-4160 <br /> 976 <br /> Contractor I�/T �,O/f�ZPOt/���drJ Address L}S�5S TA(,µEto ?3I Vl� Lic# 137 4 Z7- Phone#McO 3-72-9100 <br /> subcontractor V~ w I✓.0 !I r'h�_._ -�r1 Address; 0. zo r s 1 Lidf S 7 Phone# 7Q� 37t/ ,ZS/S <br /> 7�0 90 v <br /> WORK TO BE PERFORMED <br /> 1 NEW WELL f CORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# p OVER-80RE <br /> 1 WELL# MW-(o U PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: lestAcl -t'wb eFFs,-M MoolT09UP& LiiLLC FoR ALL bft CIAVAI L CO. 2fo700 S.?r n. QonD IRALy <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ! HOLLOW STEM DIA_OF BOREHOLE 8" MULTIPLE CASINGS?0 YES U NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SLIAEDya 40TYPE OF CASING' o STEEL D PVC U OTHER <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 101 TREMIE TYPE TO BE USED: 0 AUGERS UHOSE <br /> fl AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: U Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' tick VELI <br /> U 501E BORING U HAND AUGER APPROX.BORING DEPTH Z�� �_ __ . D BOLTED TRAFFIC BOX Or 0 STOVE PIPE <br /> 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for <br /> which this permit is issued, I shall not employ persons Subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub-contracting <br /> 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 WORKMAN'S <br /> COMPENSAT N Laws of California.' THE APPLICANT MUST CALL 48 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)468-3450. <br /> Signed / rC✓ �r�✓ "/ Title Date S�/ fig <br /> TMA P N 0 R P L Al N_ <br /> DEPARTMENT USE ONLY L; f✓r� `'�-"�L 5 <br /> Application Accepted ay Date Issued 7/ / Areae <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS- f-�7 <br /> ACCOUNTING ONLY, AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEG ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3(. 14-z011 5 0112- S� <br /> UNIT IV/10-98/MI <br />