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1,n11-x-1999 11 =41 AM FROM <br /> P 3 <br /> WELL PERMIT APPLICATION FORUM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEAF=lESVE1D-- <br /> ENVIRONMENTAL HEALTH DIVISION (PH= 1999 <br /> 304 E.Weber, Third Floor, Stockton, CA., <br /> (209)468-3449 ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM e"IMIUSERVICES <br /> App�wl Is hereby made to San Joaquin torr a pemdt to construct a for instep the work da application is made in compliance with <br /> Son Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Envirownentei Health Division. <br /> Assessors <br /> WELL Location IIP �I V3£fGf S rL Croas Street H RTI.`ti Cky c�'10 A✓Zip 2� —Pe <br /> PROPERTY Ownsr�`L AN�� Redress r 0 143 5}S C7 <br /> ity F Tat j! Plwn0±ff1'1}3SLo <br /> C47t.entraaor6l+ltur rens 7w elOt✓er, a uti C0711 LM 6e#` Z00)55m <br /> Consultant l Sub contactor CNZ711 I.11L L Addmaa[0f0x 176'k ck Wt Lica Pilo 57C�"-ZJ" 1-416 <br /> GIS Coordinates:X .Y.Township Range Section <br /> WORK TO BE PBRPORMED <br /> TEW WELL/BORING KGNEOPROBE,HYDRO H•HAN UGM OTHER-) p DESTRUCTION(choose type below) <br /> 7` SOIL BORING#12 p OVERBORE <br /> LL# p PRESSURE GROUT <br /> 'ONw. <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM OW OF SOREHOLE MULTIPLE CASINGS?p YES p NO WELLCASING OIA_ <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC p OTHER: <br /> LI VAPOR p MUD ROTARY DEPTH OF GROUT SEAL. TREMIE TYPE TO BE USED: p AUGERS pHOSE <br /> p AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 107 <br /> 14S01L BORING p HAND AUGER APPROX.BORING DEPTH B BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 13 OTHER.—C OTHER CONDUCTOR CASING PROPOSED? (if YES,liat specifications here): <br /> COMMENTS- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I herebY 060y that 1 have Prepared this application and that the work will be done M accordance with 3jr,Joaquin County OrdinenCes,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or Ncensed agent's spnabxe certifies the following: 9 cerflfy that in the perrormanca of the work <br /> for whkh Ods permit is Issuer/,I shall not employWaons subject to WORKERS'COMPENSATION Laws or Calirarnla.^ Contractor's hiring or sub <br /> Centaeirg tdgnst roCerr' s the following:11 ce r )at in the peAormance of the work ror whkh this perm#is Issued,t she#empkyParsan$subject to <br /> WORKERS' Law$Of Ca#k <br /> E 1 ­1ICANT. US ALL 40 WORIQyG..HRS;ill ADjVANCE FOR ALL RREEQUIRED INSPEC IDNS. <br /> Signed>< Trtk b1cb1 yRpGEo(o G``1 oats L I I cl, 1 j <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: (o j Id 9 � <br /> .1DEPARTMENT USE ONLY <br /> Application Accepted By IV' —"��"'� 4,rf-/ Date Issued fl Area <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC'a <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQ UEST# INVOICE <br /> z 33 <br /> (,,57 LICENSM.CONTRACTOIC.lYITJST1SIGI-4 INCENSE WFORI W':COMPENS.iATION DECLAkA'nON <br /> vNIT rV-6/23/99/sign blq g/MI <br />