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' I <br /> WELL PERMIT APPLICATION FORM UNIT IV . <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES_ (' u <br /> VIRON MENTAL HEALTH DIVISION (PHS-EHD) ! !/; <br /> -E: aThird F1Qo 45- <br /> ckton, CA., 95202 / (� <br /> (2 49 <br /> w N -REIT DABL ER T XP 5.7 YEAR FROIifl DAtE ISSUED <br /> plication here mads San Joaqui ounty for a permit to construct an(e/qr install the work described. This application lade in ompliance with <br /> San Joaqu County'Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. 4 <br /> j3Dr I N F h _ Assessor's r <br /> VYt:1.L L ation +/p7� �tl1 5 a Cross Street neA l?4)", City ee-- 70y Zip �/S 1rJ� Parcel# 13,V i/G O - D 6 <br /> PROPERTY Owner l?QJ �� TAddress,y4,- V e1G; S- City 7r aG/c T_Ziri,4S�-er Phone# .209 g1yP <br /> C-57 Contractor PA-S7- 76 X fAA0)&0*k d e,,IV 7 Z TeWW(-- AVe; cit Q'Gta wit ip�i ,iio. rair-Pnone# s7o 2.3 2-27 2 <br /> Consultant�strx?0�'t1Vt��u.tMwwNCsS Address_ �� r�d)r c;WA"5M�yz;_ Phone#.SS 0 5��472z <br /> a x. GlS Coordinates:X�f h(v-�1 .33,d., -:Y_.,y�.l�/0 0 Township �I"•�"" Range.F '""'.��yG� '.-"�: .�..r7.. - Y <br /> � Section <br /> WORK TO BE PERFORMED <br /> N"""""&BWl BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OT14ER") (I DESTRUCTION(choose type below) <br /> ASOIL BORING#._ Z __ _ Q OVER-BORE <br /> WELL# PRESSURE GROUT r <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA-OF BOREHOLE 2 r : MULTIPLE CASINGS?p YES 2CNO WELL CASING DIA: <br /> U EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING: a STEEL 1]PVC Q OTHER: <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS pHOSE <br /> U AIR SPARGE PUSH POINT GROUT SEAL PUMPED: a Yes o No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30'? <br /> ,SOIL BORING Q HANDAUGER APPROX.BORING DEPTH 3S r a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> Q OTHER _�OTHER CONDUCTOR CASING PROPOSED? /VQ - (if YES,list specifications here)' <br /> COMMENTS. S ! o r/ /V C-S D )V <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 l shall not employ persons subject to WORKERS'COMPENSA770M Laws of Califomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> w WORKERS'COMPENSATION Laws of California-- <br /> THE AP ICANT MUST CALL 48 HRS IN ADVANCE FAR ALL REQUIRED INSPECTIONS., <br /> .� Signed title l.aw3irecit fo�r.�� Date 5 � <br /> SEE SITE MAP IN UN T IV WORK PLAN DATED Z zaao <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout inspection By Date Finai Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK&CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C:S =LICENSED ON'IRAG C?I M iSI;S�N ENE& Q '„ ? P� 'LTON� CLARA <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> Z -d WiJtid Wb'V�=8 6661-9Z-L <br />