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t ( t fSf <br /> WE'D PERMIT APPLICATIONVORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICC <br /> BVED <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) AUG 16 1999 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209x468-3449 ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUEDRERMIT 1 SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/Qr install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> W <br /> L (� r'A -(Av wet L:o4 Assessor's <br /> WELL Location 5E O6r'[l IN OT Ofoaerb4 C ww► Cross Street Aenol City TYatGt-f Zip �657(p parcelti2Aq_210—36 <br /> PROPERTY Owner Rick MAMS�t e(A —.Address 13MO W-&ravwtt bat Ra.CityP a4 Zip 537 Phone#I01-$37-152$ <br /> C-57 Contractor bYCL` yin 4 ew 111nn.T,nrAddresS JWWDO S_ c50& t,`t City Zip`14ft ff LidF ko7Phone#570 7-%7 <br /> Consultant/Sub Contrai Address 2101 fbf. 124{1I'10erCitya d_Lic1r "—'— Phone#516Ycb3-Y100 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> kNEW WELL/BORING(CPT,GEOPROBE,CO-1 <br /> HA -AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORIN0 OVER-BORE <br /> •Other. 0 WELL# 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES `]]�NO WELL CASING DIA:KAr <br /> 0 EXTRACTION trAIR HAMMER/ORIVEN CASING THICKNESS NA TYPE OF CASING: U STEEL 0 PVC 0 OTHER:_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N-4 TREMIE TYPE TO BE USED: Q AUGERS allOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ;KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> `Q COIL BORING 0 HAND AUGER APPROX. BORING DEPTH ItG� <br /> �.,�_ Q BOLTED TRAFFIC BOX or 0 STOVE PIPEµ/k <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? <br /> __AA (it YES,list specifications here): <br /> COMMENTS: 60.( (Doci,na d' 4 rafo qt o CA.V%Awar_�C.Ir- S APU —4 6r%ne a farutC�l Upon Y1 mw+nl f t Oh <br /> v I <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 Joagyin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this permit Is Issued,l shall not employ persons subject to WORKERS,COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATfON Laws of Califomia." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR/ALL REQUIRED INSPECTIONS. <br /> Signed x -.-.Title=jl�("1'T (�e6l6q r S r Oat uA 10 lqffl _ <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY / Q <br /> Application Accepted By Date Issued ( Area <br /> Grout Inspection By Date Final Inspection By Dare <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> v <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 4020 Z <br /> UNIT IV-6/23/99/sign bkpg/MI ..... ......�- _ ..xc:. e. :ru..._ .,-..6-. _ •::..:� ._.:�' ..,, <br />