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JUN 011999 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESNIT IV <br /> ENVIRNMENTAL 704 E.Weberr,,Third Floor.STOCKTON. COA 95202 ENVIRONMENTAL HEAL.TF <br /> (209)468.3450 PERMIT 1 SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <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 Title.Chapter 9-1115.2 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 'I <br /> rneq�'s���4t�•,�I �/- � ors <br /> WELL Location S J Cross Street tl"1' "IT. Peasn # 1 <br /> ZI0 da <br /> PROPERTY Owners Name 5AMrS Address 340 55;15- JEV� fW8 Phon,0716 -53L-Z <br /> IZ6 <br /> lvrc 20C) <br /> Contractor Address ZZZ � (AfIPALL� E7421LcA Phone# L05--p6Z-7-1ZL <br /> \I_1�Iv moi` 7� L <br /> Sue Contractor Address Z37�2 ivl.6�ST.ST6 7 Ltd# PnoneK SIO-Z6c-096(o <br /> rra" y�it t�'b c�— <br /> WORK TO BE PERFORMED Ue TO 12 I�Ut-I�ZI4;5 7141, St�C1�LZ S <br /> NEW WELL/BORING(CPT.GEOPROBE. YDROPUNC HAND-AUGER. OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING 0 Q OVER-BCRE <br /> Q WELL It Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES 0.40 WEL_CASING DIA'_` <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING. 0 STEEL 0 PVC 0 OTHF-: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 52�S=J'. J AUGERS OHCSc <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yea a No jNGTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER APPROX.BORING DEPT)-: Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 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 wilt be done in accordance with.San Joaquin County Ordinances, State Laws,and Ruies <br /> and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: ;'certify that in the performance of the work to <br /> which this permit is issued. l shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California.- Contractors hiring or sub-cantracting <br /> 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 WCRKMAN'S <br /> COMPSVSA71ON Lawit of Calif�or�r()ia" E APPLICANT MUST CALL 48 HOURS IN A�DtVANCE( FOR ALL REQUIRED INSPECTIONS AT(209)468-3450. <br /> Signed V- -30C WF.��1VVilw�Tide /"10{L 19�).OGIs'r Date slZ.7111 <br /> V / <br /> II VIII III II ! II <br /> 11 tI MI A ! ! I ! 1 I VIiiI 01 I <br /> II I ! 1 Illi ' Il NI I I T-1 I ! III ! ! <br /> I I I I I I l i i I I I I I i I I I I I p I <br /> ARTMENT USE ONLY Ac- <br /> Application <br /> z�1 Ci 1 <br /> Application Accepted By l: ` � V Date Issued J w,a / � Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date J� L <br /> COMMENTS: N(I cc �t�YYA r �Vkt r <br /> ,-n 'tt <br /> ACCOUNTING ONLY: I AIDR FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOrCASH I RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> ZLl 1919,9) 1 f/z 12 A41Ib 91 i <br /> ri <br /> UNIT TV/10-98/M7 <br />