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WELrPERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESR <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Countv Develoriment7dle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> !3�� Assessor's <br /> WELL Location_ i. ����.//( ML1oc,CL Cross Street; AL&� ;ity Stop K1nn Zip g5Zfl7Parcel# p� 1 <br /> PROPERTY Owner! NGL 4ii�E I Address- *16 n. _City S jegKTort ZipgSZal Phone# Zorj 7J1—nJ:1 <br /> W£57 Z Iva} 5}, R�rvcNo <br /> C-57 Contractor Del II rlli. AddressSZ31, Fid 2_�If rL I City coon„a zipL)574zLidtS5yN7tiPnone# / Ok 72 )6 <br /> —T <br /> Consultant/Sub Contractor A , CIF Address_y OA5 Ail (Ari IfJ,City S%M k/f� Lic#.kiiii hone# a5 l) p 6 <br /> GIS Coordinates:X , Y ,Township A � Range (0 E Section �. <br /> WORK TO BE PERFORMED <br /> ;�NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> Other: WELL# /A 1Al=7& 0 PRESSURE GROUT <br /> IF <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> Jrk4ONITORING �'FIOLLOW STEM DIA. OF BOREHOLE Fi-i'n( 1+ MULTIPLE CASINGS?0 YES �NO WELL CASING DIA: Z60 <br /> 1 <br /> \\ s'C 44�IE 'P <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL /I�VC aOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z FCC-t TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yeso (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH ZS EC} VSOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? Nb (if"Y ES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS I <br /> 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 /> `or which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor s hiring or sub- <br /> :ontracting 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 /> NORKERS'COMPENSATION Laws of California." <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN A,�D(/[J�p"NCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title I /r+o�p f.t' �Pd/ TDate /r'Q x �" Z a.�.c <br /> - 2 t(-'� t <br /> SEE SITE MA N UNIT IV WORK PLAN DATED: (p ( DSC-Embi12 115 <br /> DEPARTMENT USE ONLY `, <br /> ,pplication Accepted By Date Issued ��Y GO Ar 4-Op <br /> 7 <br /> ;rout Inspection By_ Date Final Inspection By <br /> )estruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> NuJ e`( 5 Gt# -1y <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> 'NIT IV- 6/23/99/sign bkpg/MI <br />