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QUELL PERMIT APPLICATION FORM �- ;, UNIT IV 7 <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' �QFtc- ✓ S 0� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ". <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 J <br /> (209) 468-3449 FILE C T r <br /> NON-REFUNDARI <br /> Application is hereby made to ban Joaquin County for a permit oco sttlruct and oEinstallEheRwoRkOde DATE ISSU 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, <br /> WELL Location tW <br /> Environmental <br /> tal H <br /> ea. <br /> lth Division. <br /> Cross on. <br /> Cross Street Z3Assessor'sd, Parce#PROPERTY Owner Address Zip S2& PhoneZZJ <br /> C-57 Contractorddress-3233 <br /> �i11,,�� , gQZ` City9E�Zip 5'72Li�j�j`�Phone#/b %? 727 <br /> onsulta /Sub Contractor t-'� �! Address'��'� fU _•4 �7//ee--``�\\ <br /> iCity S�>t�L} Lipp Phone# <br /> GIS Coordinates:X ;Y t <br /> Townshi <br /> P-----L—Range Section <br /> WORK TO 8E PERFORMED <br /> ,24EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER') <br /> 0 OIL BORING# 0 DESTRUCTION(choosetype below) <br /> WELL# / r f 0 OVER-BORE- <br /> 'Other; r 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,"ONITORING HOLLOW STEM DIA.OF BOREHOLEa i <br /> MULTIPLE CASINGS?0 YES �O WELL CASING DIA: Z <br /> 0 EXTRACTION <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESS I TYPE OF CASING: 0 STEEL PVC 0 OTHER: ) <br /> 0 VAPOR 0 <br /> MUD ROTARY DEPTH OF GROUT SEAL = TREMIE TYPE TO BE USED:,,U'UGERS pHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: <br /> 0 SOIL BORING 0 Yes/$No (NOTE: AXIMUM FREE-FALL DEPTH IS 3t7'} <br /> 0 HAND AUGER APPROX. BORING DEPTH BOLTED TRAFFIC BOX. or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: L madd <br /> f <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: "I certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 7 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 APPLICANT MUST CALL 48 WORKING HRS.,IN ADVANCE FOR'ALL REQUIRED INSPECTIONS: <br /> Signed x UU Title l6 Date 212,1)1" <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> - //• zooc� �S/ <br /> Application Accepted By Date Issued Area o <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE i <br /> o� 7WOZ 31 2_ Ii 30 9R# D /631 <br /> C-57 LICENSED CONTRACTOR MUST_SIGN LICENSE &WORKERS' COMPENSATION DECLARATION i <br /> UNIT IV-6/23/99/sign bkpg/Mr._ A ._ .. . <br /> i <br />