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• UNIT IV <br /> WELL PERMIT APPLICATION FO M <br /> SAN JOAQUW COUNTY PUBLIC HEALTH SERVICES <br /> r , F� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Out � ' 604 E j*Air, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED <br /> pplication 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 /> an Joaquin County Development Title, Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> L1 ��1 �,�,w,,-T Assessors <br /> VELI-Location 3 i wQ$I GLA SIFT Cross Street City C�*A) Zip 9s�� Parcel# T + C <br /> _ py,f Srtti�� <br />'ROPERTY Owner SSI l°l f d Ps'-� Address kJe5 ST C+tY S'' °^S Z+p�1�Z0� Phone# 948— d3dL <br /> 1 <br /> -57 Contractor MF BSI ddress 53(00 s WJAT AZ- C11Y Sly' ZipCISM0 L+c#k7Z /7Pho1e#Ad <br /> onsultan Sub Contractor 640&200-C�� C Address 4t 5Al Mkc^3 V City SI Lic# Phone#¢�7-10.OW _ <br />;IS Coordinates X Y Township Range Section <br /> YORK TO BE PERFORMED <br /> KW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 OVER-BORE <br /> SOIL BORING <br /> DPRESSUREGROUT <br /> R,V�IELL# — <br /> Other <br />'.OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSt+ <br /> ITORING OLLQW STEM DIA OF BOREHOLE Y*fa MULTIPLE CASINGS? 0 YES `[ WO WELL CASING DIA Z s, <br /> CTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCA—40TYPE OF CASING 0 STEEL THER <br />]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDUGERS OHOS3 <br /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED 0 Yes �(NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br />+] SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH-D�,45'5"0 Gid+ 1] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER o OTHER CONDUCTOR CASING PROPOSED�_/)U (if YES list specifications here) <br /> COMMENTS <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, f 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 TRE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQ UI�ED INSPECTIONS <br /> Si ned x TitlelCompany S�FFGrs1a ✓/�I i rf <br /> 9 <br /> 1eS1 Wrao <br /> Print Name 10N //�ACICLk DateP/cterk�? <br /> SEE SITE MAP IN- UNIT lV_ WORK PLAN Dq TED: <br /> DEPARTMENT USE ONLY �/D� <br /> Application Accepted By m ate Issued �""' Area <br /> PP <br /> Grout Inspection By ate Z l'.t inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDI[TI NS M <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1/113/2000 <br />