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WEAPERMIT APPLICATION I RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> )C ' # <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 0 9 1999 <br /> (209) 468-3450 J' ,�eaMENTAL HEA,_ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS5P}HptW/SERVICES <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 /> Assessor's <br /> WELL Location ross Street g V-VCity i Zip C <br /> e177�6 <br /> PROPERTY Owner>f"W 4^^•IVOW V 7uS� Address -iL71 Lam• 06e,4Ae4 �ity/,�QeAC•��.�Ziv l�,Salsnone# 4/�$3�1Z� <br /> C-57 Contractor Address /�P� ity.s Zip�uG Phone# 4 !O <br /> Consultant/Sub Contractor Address City Uc* �— PhoneZ 7 l0 <br /> SIS Coordinates:X , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT. GEOPROBE,HYDROPUNCH, HAND-AUGER.OTHER-) 0 DESTRUCTION (choose type below) <br /> VSOIL BORING d I 0 OVER-BORE <br /> O WELL x 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM - DIA. OF BOREHOLE ca " MULTIPLE CASINGS? D YES XjNO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE CF CASING: O STEEL 0 PVC D OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -5,0/ TREMIE TYPE TO BE USED: '(AUGERS 0HCSE <br /> 0 AIR SPARGE *PUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 3O __ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: <br /> CONDUCTOR CASING PROPOSED (if YES. list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that I have prepared this application and that the wom will be done in accordance with San Joaquin County Ordinances,State Laws, and Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensec agent's signature certifies the following: "I certify that in the performance of the work <br /> `or which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSA77ON Laws of California." Contractor's hiring or sub• <br /> antracting signature certifies the following: -1 certify that in the performance of the work for wnicn;his permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> THE P NT MUST LL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTION-7S. <br /> Signed x_: <br /> TitleV/10 Date ! <br /> SEE SITE MAP IN U IV WORK PLAN. DATED &17lti <br /> l� DEPARTMENT USE ONLY <br /> Apolication Accepted By 01A Date 1 •1-���1.��..^^�'� Daattee Issu/evd I; Area <br /> Grout Inspection By <br /> C-�� Data 5 I I'i"(9� V tlr-Snal ttl�2a Ion By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK'#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> SR# D 101 s 3 <br /> UNIT IV- 5/99/MI <br />