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WEL-, PERMIT APPLICATION f SRM UW IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD" <br /> ) OT <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 F/1/� O 0 <br /> (209) 468-3450pFA�fV1ijF� 4 1999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T/��41lf' � <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 Joaquin County Development Idle,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> h�• Assessor's <br /> WELL Location w; 15 0�l ti/a� Cross Street `"00 i 0 cI4 1. City S)o C 14 )6 V) Zip G h}O y Parcel# <br /> PROPERTY Owner �tire(��r Address X115 �yvS�Q ��vC� City 1`I 17ovactU �pQ `j E13Phone#530 AZO �{S71 <br /> C 57 Ccntraaor dya v(c"j °c Ny i roe,VV'Address -`100 5- 1W lw�t6on Way City ST 1�W Zips�}O i Uc#61Phone# L467-1006 <br /> Consultant/Sub Contractor Address CityLim Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED �\ <br /> O NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH, HAND-AUGER.OTHER-) O DESTRUCTION(choose type below),_C <br /> 6,SOIL BORING# 0 OVER-BORE <br /> WELL# O PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DtA. OF BOREHOLE MULTIPLE CASINGS?p YES 6 NO WELL CASING DIA: <br /> 0 =XTRACTION 0 AIR HAMMER[DRIVEN CASING THICKNESS IVIh TYPE OF CASING: Q STEEL O PVC D OTHER:,_ <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T- P• TREMIE TYPE TO BE USED: O AUGERS $HOSE <br /> ]AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: O Yes OJ' <br /> No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')� <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 3(3O BOLTED TRAFFIC BOX or O STOVE PIPE O <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? V (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i nereby cerci y that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws. and Ruies <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.I shall not employ persons subject to WORKMAN'S COMPENSA77ON Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies:he following: 'I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> __ THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x.�'1J�ir ��/ �Ir-� Title pv'o �c7 6,0 c) 0 s Da <br /> // te 3b -qcf <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 30 5, � <br /> / DP/gRTMENT USE ONLY 3J_0 <br /> Application Accepted By 1}� vv/ Date Issued i Area <br /> Grout Inspection By f Date JZN,61 1Cf Final Inspection By Date <br /> Destruction Inspection By Date ; <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH I RECEIV D DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> (Z µ <br /> UNIT IV-5/99 /MI <br />