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LS-G�- hey I I : I0AM rKur-1 F', a <br /> to 0 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RONMENTAL HEALTH DIVISION (PHS-EHD) Ark <br /> . Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 .1 T. <br /> 4*Joaquin <br /> -'SER ALD, <br /> -REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED V I LCS <br /> application is herebyty for a permit to construct and/or install the work described. This application is made in compliance with <br /> ian Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> �I����� E110NT AND c, Assessors <br /> NELL Locadon otu 6WNDED BY bNCO`ir Cross StliZ f nn�i City OG {p Zip Opt Parcel# SEE WORTS kM <br /> PROPERTY Owner r iy OF kxK-foPu��--I Adddresssl&a N.EI 1209AVO 71. City •, ?'OAl Zipg5;ZO;L Phone# r�9p I- O <br /> -57 Contractor�IawguM EXV08m, 1'/Address A% W iwAm k vy City TmT�I�I Zip�Lic# I�K68 Phone# ul - IR <br /> �,f I uiT6I <br /> :onsultant/Sub Contractor� IJN1ERaIlO Address 555,dot1f6omE�Y�1f.' CitvrXwfRIWCiSColic# Phone#l4rs qs -r1 <br /> 31S Coordinates:X ,Y .Township Range Section <br /> NORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE. HYDROPUNCH. HAND-AUGER,OTHER-) ,)KDESTRUCTION(choose type below) <br /> XSOIL BORING* 143 809;1,365 FROIA 3't0 1 D OVER-BORE <br /> 0 WEEL# SBodey N6S MER I5'+0 CoIIECT.64 APRESSURE GROUT <br /> Other. �-W'BORING-t <br /> ;OMMENTS <br /> 'YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE J:jHG MULTIPLE CASINGS?a YES NO WELL CASING OIA:_ <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS .131Q4 TYPE OF CASING: p STEEL (,PVC p OTHER: <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS CHOSE <br /> I AIR SPARGE PUSH POINT GROUT SEAL PUMPED' 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> I OTHER KOTHER Q�� CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, ane Rules <br /> nd 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 parsons subject to WORKERS'COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br /> ontracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to <br /> YORKERS'COMPENSATION Laws of Califomia." <br /> H/E/pP�PJ(/SCA T MUST CALL 48 HRS IN ADVANCE FOR ALL/REQUIRED INSPECTIONS. <br /> igned x i/�/ ICS/ Title /1167 6G�f /K�kvlrt Gv Oate_ VA/U <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY / j, I I / /'T /O <br /> pplication Accepted B1,y (,,, f O'e (_, <br /> Date Issued I' ( O Area Zw/ <br /> rout Inspection By Date 2 teal Inspection By Date <br /> estruction Inspectiory,By Date <br /> OMM TS I CO TTI NS: d- a- <br /> Le I a <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> =0 l 36 2U�. 1 yoo '$ <br /> C-57 LICENSED CONTRACTOR MUST SIGN LI RKERS' COMPENSATION DECLARATION <br /> NIT IV- 6/23/99/sign bkpg/MI rr <br />