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WFnlr_ PERMIT APPLICATION r2:RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EECEob(�� <br /> 304 E. Weber, Third Floor, Stockton, CA., 952112 V LLSS <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU �INQy 1��O�T2005 <br /> Application is hereby made to San Joaquin County for a permit to censfruct and/or install the work described. This ii hkNie '� <br /> Joaquin County Development Title,Chapter&1115.3 and the Standards of San Joaquin County Public Health Servi k 1�+��1I nce with San <br /> $�� V•`.�f., Y7 M&'Frtgl Division. <br /> WELL Location c, Assessor's <br /> SCross street B��y�..-, C;ty (�{�, ZrP, S Zc/O ParceNf G5�5 - pyo-3 Z <br /> PROPERTY Owner 5%.Fzh a-4 FGr'M i n�A''Addres?h 28 H' WS <br /> (.-7� e' nS t"1a nv v2 nc� . Zip Phone# fv"TAvz.,r�S« <br /> C-57 COnlfantOr_ Dri ll� � I ��..y�-�� C7i t��l? 49 <br /> �Sj .•,t )lddres7 -4N 11q <br /> / � _ "' c>� P c# Phone# - /j-` •-�r> <br /> onsultant Sub Contractor b'�� Zrnlr• JeL lgydress u, 0 I-[oIl-j Ci �,.v-r 11e cA- <br /> GIS Coordinates:X - ty— L� Phone# �'-'e%T�� 3Jy <br /> •Y ,Townshi <br /> P Range Section <br /> K TO BE PERFORMED WOR <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) <br /> ,$501L BORING DESTRUCTION(choose type below) <br /> ELL# !vt W-t Z wt t..�-/ 11 OVER-BORE <br /> `Other: YH W -1 S' 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING /1{HOLLOW STEM DIA OF BOREHOLE to " MULTIPLE CASINGS?11 EXTRACTION VAPOR r� U YES 0 NO WELL CASING DIA:_ <br /> AIR HAMMER/DRIVEN CASING THICKNESS 51 h k0 TYPE OF CASING: II STEEL / `PVC Q OTHER: <br /> 11 0 MUD ROTARY DEPTH OF GROUT SEAL jJJ!D TREMIE TYPE TO BE USE AUGERS []HOSEAIR SPARGE Il PUSH POINT GROUT SEAL PUMPED: 11 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> D SOIL BORING- 11 HAND AUGER APPROX BORING DEPTH--T-15'd? a BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> I]OTHER: It OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: ravr. Ll.. G t r <br /> I n f�--`-- �l �b-t� 5 1✓' wrin c.�_ Sp-.� 1 -.,•-7 r S '�.+�1.'S.zy( <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,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 California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING,HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed z /e, _.__ _ - ___ Ttle/Company_ _ <br /> Print Name t tate <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: , I'1 <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By ' C 1-", �Date.Issued__ r "4✓ /7. L�� Area <br /> Grout Inspection By 11,vy Is, c in Date L 1-A2 Final Inspection By Date <br /> Destruction Inspection By V A Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACR <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 '39 .00 1 r u a �- <br /> visjzcce <br />