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T <br /> WEEL PERMIT APPLICATIONf RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 C r <br /> (209) 468-3449 ( L r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for i permit to construct and/or install the work described. This application pp on is made in compliance with <br /> San Joaquin County Development Title Chapter 9-1115.3 and the Standards of San Joquin County Public Health Services,Environmental Health Division. <br /> On-SiTL �.bels) CAAIAL. AvE T•NeAn7on o66 Assessors <br /> WELL Location_FI AG Cl' T_, C-Np„RDn Cross Street CAP;+al &%,t City 14107=- 'Zip95.avz Parcel# OSS -326 -4- <br /> PROPERTY OwnWer iLAARO 17nK iDE Address 64., 1 CAL AL Q.,E , Cay QD 2 Zip95Zt/2 Phone 2n 3 -53340 <br /> C•57 Contractor W -511442-- MA 1 Address3,�33 f'r4z:E5era 54. Cay q`ip O'A Zip9574a Lic#5 79phone# <br /> Consultant I Sub ContractorrL N, tvi Iter. <br /> Address�00✓� Wr City STaU(Ton Lic#�z�Phone Zoe 4 /oo }, <br /> GIS Coordinates:X , Y ,Township Range9 Section1y_ <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING PT GE L LOBE, HPDR PUNC ,HAM, -A GER,OTHER-) D DESTRUCTION (choose type below) <br /> OIL BORING# f 0 OVER-BORE <br /> 'Other: D ELL# �. /' /Ip 0 PRESSURE GROUT <br /> COMMENTS: 'yWv <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE Z-i m )4 MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:N/A <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIR TYPE OF CASING: D STEEL D PVC D OTHER: 117/1—d - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Tcl A L IRP7,4TREMIE TYPE TO BE USED: 0 AUGERSNOSE <br /> 0 AIR SPARGE AkPUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IJ 301) <br /> $�3OIL BORING /a HAND AUGER APPROX. BORING DEPTH )S_ FF£ 4- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D THER, D OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: ba"En Or\ CPT F-11N Ana �, AcAallbno, I c1 S7o on r 2115 tvi'l) he lnSiA/ I r <br /> G-F A LA7F✓Q (k•ay AT TNi5 P4 AC r , <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: 'T certify that in the performance of the work <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: "/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 California." <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x oW, C o %�/ TitleTADiC'L± Ir/''PPID ;t; Date 0 3^Z 2 -o o <br /> Jr� . <br /> SEE SITE MAP, IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 061W4pplication Accepted By Date Issued Area Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES TFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35o MW '17f) 3� •Z D2-2-353 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JNIT Iv- 6/23/99/sign bkpg/MI <br />