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WEL;/ERMIT APPLICATION <br /> ZM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)'468-3449 <br /> Application is hereby made to San Joaquin County <br /> NON-REFUNDABLE <br /> a perrmit o co sltruc and IT REnsta I heRFROMwork described.SSU application i <br /> San Joaquin County Develop;nent Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental s made in compliance with <br /> WELL Location 7 R. <br /> --7� 7W f 1 .�R ental Health Division. <br /> / Cross Street t, �{y� City Assessor's <br /> PROPERTY Owner?"e W1y►�/ ,� �P �` ParcewAfg 1S"n -/4Yo- <br /> I. Address yLpR w0i7.7-,�j <br /> C-57 Contractor ddress[Ik,.IVA✓ EX�%i4p 1 , y ZiP_ r��Phone# rL s <br /> Consultant/& N Ih t City _ZiP '�— Lic X Phone#_,Fin Z4. 5y27 <br /> Address City���l <br /> GIS Coordinates:X-L7 3 e Lr ' Phone#S/o sb v77Ji. <br /> q- Y- �/S/? /� Township ��rz Range It r E <br /> WORK TO BE PERFORMED Section_ Z- <br /> NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# `DESTRUCTION(choose type below) <br /> Other: /{/I k J 0 WELL )KOVER-BORE <br /> 'OMMENTS: G F 0 PRESSURE GROUT <br /> -YPE OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE L ~ <br /> MULTIPLE CASINGS?(I YES JKNO WELL CASING DIA: -�v a <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES <br /> I VAPOR 0 MUD ROTARY TYPE OF CASING: 0 STEEL �pVC 0 OTHER: <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> " 0 AUGERS OHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: <br /> SOIL BORING Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q HAND AUGER APPROX. BORING DEPTH ..Z D a <br /> OTHER: D OTHER 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> (if YES.list specifications here): <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> iereby 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 /> id Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "f certify that in the performance of the work <br /> r which this pennit is Issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> ntracting signature certifies the following: `/certify that in the performance of the work for which this permit is issued. l shall employ persons subject to <br /> ORKERS'COMPENSATION Laws of California." <br /> THE PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> fined x 14 Title///�RII�iJ %,t- <br /> Date_A9 AaJ /'9J f <br /> 33EE ITE MAP IN UNIT IV WORK PLAN DATED 44 <br /> /� DEPARTMENT USE ONLY <br /> Plication Accepted By ! i, _� 0 p?� Date Issued__ ��-�/ 2 lq`J <br /> 3ut Inspection By Area O Z 3-fe <br /> Date Final Inspection By <br /> stniction Inspection By Date <br /> Date /3- a p- <br /> 1MMENTS/CONDITIONS: <br /> CCOUNTING ONLY: AID# FAC# , <br /> CODES FEE INFO AMOUNT REMITTED (�#/CASH RECEIVED BY DATE PERMSRifIT/SERVICE REQUEST NUMBER INVOICE <br /> 0f y 0110 p osRit I y y 6 I <br /> -57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS'COMPENSATION DECLARATION <br /> IT IV-6/23/99/sign bkpg/MI <br />