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WEAPERMIT APPLICATION *M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pernit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development rAte.Chapter 4-111 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> G / -},,L�ZC I Assessor's <br /> WEA_'..Location yl/t7 6.42e,J.P Cf,S �� Cross Street City. `� f� /N zip Parcel t <br /> PROPERTY Owne'rI �h 1 �I r a I-tC'rt Address �t.jlG 7.-e2 City/ "ch f ZJp%5 Z3 ?honeC . J� -LY2 <br /> ;-57 Contractor V�tI XX el`14 City �5 <rLp`754/ Liu?72t�0`�Phonez 2ZLL 7�5'/OC7 <br /> / 2dy S CSN uog 3475 Phonet �7--312 � <br /> Consultant/Sub Contractor ^YN'/Lui Address �C1tK J� Ory <br /> GIS Coordinates:X <br /> v Township Flange Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL I ORI G(CPT. GEOPROBE,HY0R9FUNCHH.HAND-AUGER.OTHER-) U DESTRUCTION(choose type below) <br /> SOIL BORING: `( 0 OVER-BORE <br /> SOIL 0 PRESSURE GROUT <br /> -Other: <br /> COMMENTS: <br /> -.YPc OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> >AONITORING HOLLOWS 1 cM CIA OF 3CREHOL^ rf rr MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA:_ <br /> 0 TRACTION 0 AIR HAMMEPJORIVEN CASING 7 HICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> EX <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT S'v1L Ikr;� TREMIE TYPE TO 3E USED: O AUGERS GCSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. 30RING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED (it YES.list specifications nere): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i neregy certify that I have Prepared this application and that the work will be done in acramance with San Joaquin County Ordinances. State Laws, and Rwes <br /> and Regulations of the San Joaquin County. Homeowner or licensea agent's signature certifies the following: "I certify that in the performance of the work <br /> ` <br /> or which this permit is issued.1 snail not employ persons subject to WORKMAN'S COMPENSATION Laws of Califbmia." Contractor's hiring or sub- <br /> contracting signature certifies the following:-/certify that in me performance of the work for whicn dis permit is issued.I snail employ persons subject to <br /> WORKMAN'S COMPENSATION Laws or California.' <br /> THt%E�APPLICANT MUST CALL 48 HRS IN ADVANCE FOR/ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> C/t�' — Title �✓�, t"c vn.t,wrr{� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 71?-5 <br /> DEPARTMENT USE ONLY �p <br /> --f Date Issued 0 2- 0 ( Area <br /> Application Accepted By 1+ l i t)t Date B 2 <br /> Grout Inspection By � � �4 U t � Date <br /> '� 3`) U I Final Inscecbon By e <br /> Destruction Insoection By Date <br /> COMMENTS I CONDITIONS: <br /> FAO: <br /> ACCOUNTING ONLY: I AID# <br /> PE CODES -FEE INFO AMOUNT REMfTED I CHECKWCASH I RECEIVED BY I DAT. I PERMIT/SERVICE REQUEST NUMBER i INVOICE <br /> 3SoI 8 1 c I 32-- I <br /> UNIT IV-3/99/MI <br />