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�.. ..r. F <br /> WE PERMIT APPLICATION V- ORM UNIT IV <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICESMA <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") 1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 ,I APH 12 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ii <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 4 19 Gkg%-tey Cross Street ievir Kevgd city' 5l.}oCkTG!1,_Zip 95-405 Parcel# 151-3-f() <br /> r PROPERTY Owner Wtntfe+r4r Altxqn#erZAddress !.0-00x �6� -city o[w Zip 95010 Phone# 0 d 5-I$S3 <br /> ., 3 Lic# <br /> C-57 Contractor �•Pe �K`S1�'{ hC. Address 950 HOWB �R04CityMaF'tlNtz Zip94555b 0��Phone#(925)313-SBop <br /> fl Rarrtc a <br /> Co 5ultant/SubContractorRg644 -e KYIM'C , Address P'a. bX $b Cityr e Lic# Phone#(916)354'3ZSo <br /> t <br /> Gi5 Coordinates:X", r w 'm"'"" - ='. -Ys_ .-'.•„` ' '': .Townships ” .. -Range "-.. . -- Section <br /> i <br /> WORK TO BE PERFORMED <br /> II NEW WELL I BORING(CAT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> '�0 SOIL BORING# C eT- t _ 0 OVER-BORE.: <br /> 0 WELL# 0 PRESSURE GROUT <br /> `Other: <br /> COMMENTS: I{gVA�Z F.%, ro4y%thtgl Wort[ P144 . dgtgd beceuiker 131 1999 -- <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'Iia• MULTIPLE CASINGS?0 YES" 1 NO WELL CASING DIA: KA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �/� TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TD- I00`IrTTREMIE TYPE TO BE USED: 0 AUGERS jHOSE <br /> 0 AIR SPARGE PUSH POINT(GPT) GROUT SEAL PUMPED: I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH I oO--F r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE NA <br /> 0 OTHER: CONDUCTOR CASING PROPOSED?! if YES,list specifications here): <br /> y „ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i 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: "Icertify that in the performance of the work <br /> i, for which this permit is issued,1 shall not employ persons subject to WORKMAN'S 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 />�WORKMAN'S COMPENSATION Laws of'Catif&i!,9"THE AI' IC NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x f Title Date <br /> 1 <br /> SEE SITE MAP [ UNIT IV "WORK PLAN. DATED 1-1113199 t Mgp A4QCkeii <br /> [n D PARTMENT USE ONLY e <br /> Application Accepted By 'r�� Date Issued yr v Area W. <br /> Grout Inspection By Da 6 Zt M Final Inspection B Date <br /> Desiruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> Ei y <br /> :FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY "DATE PERMITISS�^}}EppR��VICE REQUEST NUMBER INVOICE <br /> Y ISR# LJV Z2- <br /> UNIT IV-6/1/99/sign bkpg/MI 7F () ii- <br /> . ;i <br />