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k <br /> ~� WLPERMIT APPLICATigN�ORM UNIT EV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION EIVED <br /> 304 E. Weber, Third Fioor, Stockton, . <br /> (209y 468-3449 SEP 2 7 1999 <br /> NON.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Tn y � � <br /> Application is hereby made to San Joaquin County for a permit to construct ane../gr install the work devv. }� ! compliance with <br /> San.ioaauin County Development Title. Chapter 5.1115.3 and the Standards of San Joaquin County Publi e�rvjo VJ,8rl6tal Keaitn Division. <br /> ! Assessor's <br /> WELL Location J �i' �r Gross Street v kris t, City ✓YC Zip� —1 — Parcelit <br /> JAILI1 0u-� `7J—CJetr u � .7 cc /02 � o .u-- G{-<-����� S '(797 ��Z ?'7zz3 jv3-J77->rr) <br /> PROPERTY ownefrlr�►�-sr/`&(, 6J V-&1y_a_ Address 'Y00 Lt=-_ City Zip `i'C3�Phone# <br /> C-57 Contractor �1S LtiJ k4k Addr ~P090;C f 6'I N/ City SKc;�"Zip� ic*4 / Phonesi 9/u/'3 73- <br /> Consultant I Sub ContractorAddress7�7Arr^atdt Lr zity t !ZLide �37`��prtonett X711-391 J <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL r BORING(CPT-GEOPROBE. HYDROPUNCH.BAND-AUGER.OTHER`) DESTRUCTION(Choose type below, i <br /> jJ SOIL BORING V 0 OVER-BORE <br /> WFLL u XPRESSURE GROUT <br /> 'Other: <br /> COMMENTS; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0NITORING D HOLLOW STEM DIA.OF BOFZEHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> �BVAPO <br /> TRACTION D AIR HANMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC 0 OTHER: <br /> RO MUD ROTARY DEPTH OF GROUT SEALTREMiE TYPE 70 BE uSf=D: [{AUGERS <br /> OHOSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> O SOIL BORING O HAND AUGER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER' U OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS-. <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 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,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: -I certify that in the performance of'me work for which this permit is issued. I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia_' -i <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> .� Signed x Title_ Sh4 t-��`L0l� r� date ZZ J <br /> SEE SITE MAP IN UNIT IV. WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Apolication Accepted By >t1 r` tet ____- ___ _ Date Issued Area I <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date jU _l 7. i <br /> COMMENTS I CONDITIONS: P t�! L' 'P. <br /> FAG# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC C6CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3S.az 60°� r78! rl-�� a o2o6go <br /> i <br /> C-57.-LICENSE-D CONTRACTOR"MUST SIGN LICENSE.&WORKERS' C0M-PFNSATI0N DEC-LARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> Z d i 4 lOtj� HV5E'8 665 l--VZ-B <br />