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FILE COPY <br /> it <br /> 'NELL, PERMIT APPLICATION FORM <br /> t2 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Cos <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 Joaou; CountypeVsropment Title, Chapter 4-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> rlV FF" C Assessor's RIDW <br /> WELL Location 1150 C >N-�.'{ C I Ufi E3a.-V�l Cross Street EFSAN tLrt� City sTi"X.Cv..ccY.V Zip * - 2c:+-Parcel# W <br /> PROPERTY OwnerCr TV <br /> c rc;y.i Address 3115 rAQgJH EL Wl2A0Q CIty4TGCKTOIV Zip CkSZCZ Phone#C'bG'l)el i I- y 3491 <br /> �.c. cTlt k <br /> C-57 Contractor ev�,c ADE De LL2NC Address ar ,.MpC CiPC.LF City coanGrA, Zips,,;>Iv 2,Lic#717''i to Phone#_L!]_uj_ i, -i 1Gy <br /> ADYTNCElI <br /> Consultant/Sub Contractor rhyit=O.y PS�NTHt_,S,c - ✓address '3','1 �,NcvW :L15. City Tcsr-k-TctSLic# Phone# 1i=.9)v6'1-te,Cuf� <br /> GIS Coordinates:K , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT. GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER') N DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER.-BORE <br /> (WELL# M PRESSURE GROUT <br /> 'Other:, <br /> COMMENTS' fLCFFt2Etv(C NT"TACHCD ',rJ-oi PI.-PIr t1ATG4 15 TAIV.y AFL} ZCU-f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `,MONITORING ',HOLLOW STEM DIA.OF BOREHOLE S" MULTIPLE CASINGS?N YES JKNO WELL CASING DIAD." <br /> N EXTRACTION 0 AIR HAMWER/DRIVEN CASING THICKNESSS(.blg cJQ TYPE OF CASING: 0 STEEL 9PVC p OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t'-3:7lsS G- TREMIE TYPE TO BE USED: UGERS OHOSE <br /> 0 AIR SPARGE g PUSH POINT GROUT SEAL PUMPED: ,$Yesr 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30`) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Ste: $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? Nr t�(if YES,list specifications herd): .__ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby sonify 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 Reoulalions of the San Joaquin County- Homeowner or licensed agent's signature cerlifes the following:"I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ personssubject to WORKERS'COMPENSATION Laws of California." Contractor s hiring or sub- <br /> contracting signature certifies the following. 'I ceriih,that.in the pertormance of the work for which this permit is issued 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed Ae. V Title/Company � TAFF SrT FNTT 4"-/All rAN[ =t7 Ec 'rvvrc2r-HNENTAt- <br /> Print Name E3EckY LFI _ Date <br /> SEE SITE WP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date Issued S Z��_Area Da <br /> Grout Inspection By -,_ Dale Final Inspection By ---Date- <br /> Destruction <br /> __DateDestruction Inspection By Dale <br /> COMMENTS I CONDITIONS:--- <br /> I D', <br /> ONDITIONS: ID# <br /> PE CODES I FEE INFO I AMOUNT REMITTED CHECK J REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> j 3 252 2- �3 OOSD6 <br />