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�-� WELL*RMIT APPLICATION FC*its UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) i. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •s� <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 /> 1 1 U Assessor's <br /> WELL Location g Z�o . Q. rbc,1_�" W o i Cross Street oLY.l S City S i o Cktft �., Zip 15 2.01 Parcel# 16-]- /S _ a Z <br /> 1J b U C( S�_18 <br /> PROPERTY Owner cq,,. , K o Z`. F� Abdress T 0 R .,I, -1 b City Kos,"i LQ Zip Q A Phone# Q 16- 7Pa <br /> Flo �I Rr� S� 0 72.Qgoy <br /> C-57 Contractor \f t,w p rC.W, Address P 13 13O:6 S 1 city ), Zi 5q'l)Lic# Phone#gl i b• 7?7 v <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> PNEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL#OR <br /> A WELm W OVER-BORE <br /> "Other: C-C", .'I-- }-,-%v ; ) D PRESSURE GROUT <br /> COMMENTS: S i >rer O F C.1 i e v $ F L rtGt-- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� ,}� Z r rn�� S� 00�,� SSZ <br /> �MONITORlNG 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA; <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> ]OTHER: 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 /> nd Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the worn <br /> or which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California.,, Contractor's hiring or sub- <br /> ontracting 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 /> VORKERS'COMPENSATION Laws of California <br /> 1 $ ` .i0tt� #��TIi11lS <br /> ,.-... <br /> igned x <br /> —Title S i-{Z_ ,Date t 1 - ) 3 - O c <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: - � L <br /> SID <br /> cplication Accepted BDEPARTMENT USE ONLY <br /> y - - <br /> rout Inspection By Date Issued_ //-/7 —C-0 Area_ D 7S—(,,Date /� AA// L ordinal Inspection By <br /> astruction Inspection By Date <br /> Date <br /> DMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK* <br /> RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �..5 U.�...._ .. <br /> F'l <br /> :y . _ y <br /> c <br /> Y � <br /> 0 <br /> I <br /> r <br /> /7 <br /> .:: <br /> 0"M iii (' •4 fi, f , <br /> JIT IV-b/23/99/sign bkpg/MI .�,•-.�. �i.��ii�'���`��, (� <br /> Z •d <br />