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8 2fi-15yti a:eyrrl rKulp <br /> r c, <br /> Coll <br /> WELL PERMIT APPLICATION FORD? UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES'^.. ,k } <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E- Weber, .Third Fioor, Stockton, CA., 95242 <br /> (209r 458-3449 <br /> EP4 vi: <br /> z;r)D <br /> NON-REFUNDABLE PERMIT EXPIRES 1 V=A In,FROM DATA=ISSUED <br /> Application is hereby made to San Joaquin County For a permit to construct anvor instalr the work described, This appliCafiOcnT <br /> San Joaquin County Development Title,Chapter 9-1 115.3 and the Standards of San Joaquin County Public Health Services, Environmemal liealt}tcII v ,an• <br /> WELL Location?�a0�, W('�� nnlniQ/"(�Ua Cross Street I iry S�L� �sor's <br /> 1 � Parcew C7�6�-3J O-/U <br /> PROPERTY owner .7 q v �� Address 00 <br /> rUl9•L Itip �'f5 cY3Phone# 17•] 33C <br /> C-57 Contractor yn k- ' dress <br /> R- �}�,,����f_,,,, ����� <br /> ` C��LLZ-4Q � l/,LiAlaiQy Phone#�r b 777-�fl CD <br /> Consultant/Sub Contractor Address �pl Sf �e t� <br /> CtY r t.icJx Phone#5o"Y�-0-33/-5 <br /> 31S Coordinates:X ' Y Township Range— 9 Section <br /> NORK TO BE PERFORME0 <br /> AEW WELL/BORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER OTHE12-) 3ESTRUCTI <br /> a SOIL BORT G a Choose type below) <br /> j�WELL# • '-A ,vlw s cr VER-BORE <br /> Other. r C a PRESSURE GROUT <br /> '0 -L <br /> U C r �o L411 1 2 0' 4✓C U t / r 1 <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPS FICATIONS <br /> QMONITORING HOLLOW STEM DIA.OF BOREHOLE " ° MULTIPLE CASINGS?Q YES NO WELL CASTNG <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICtCNESS 0 TYPE OF CASING: Q STEEL PVC a OTHER2 �T <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED: a AUGERS DOSE <br /> AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: (]Yes o (NOTE: MAxIMLIM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 11 HAND AUGER APPROX. BORING DEPTH 1 r <br /> OLTED TRAFFIC BOX or a STOVE PIPE <br /> OTHER*- fl OTHER CONDUCTOR CASING PROPOSE ? (ii YES,list specifications here): <br /> OMMENTS: <br /> NOTE: OFFSI E BORINGS REQ IRE AC SS OR ENCROACHMENT PERMITS <br /> rereby 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 /> :d Regulations of the San Joaquin County Homeowner or licensed agenrs signature certifies the following: •!certify that in the performance ole work <br /> r which this permit Is issued,1 shall not employ persons sirbJec!to WOr7tCEJ7S'COMP <br /> Laws of California." Contractor's hiring or sub- <br /> ntracting signature certifiesa following: 'I certify th <br /> that in e perfom�ance of the work for which this permit is issued,r shall employ persons Subject to <br /> ORKERS' MPENSA770MLaws of California." <br /> T 1=AP LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPE T NS. <br /> x 1(IVA. <br /> Date <br /> 3EE SITE MAP IN UNIT IV WORK PLAN DATED -Z la-s oZ' <br /> DEPARTMENT USE ONLY <br /> plication Accepted By � � (� <br /> v ,Date Issued S% - C Area n 7 j <br /> )Ut Inspection <br /> —--ir! r Date -(J1 Finat Inspection By D <br /> struction InsPeczion By Date ate <br /> )MMENTS/CONDITIONS: a ,� /^-dc-J L.s e�I� SC: ,' �k <br /> " W11 <br /> CCOUN7IN(3 ONLY: AID# FAC# <br /> =CODES FEE INFO AMOUNT"REMITTED HECK CASH IL <br /> RECEIVED BY DATE PER VI1T/3ERVICc REQUEST NUMBER INVOICE <br /> '57 LICENSFp CONTRACTOR�U <br /> t�sIUS S�Gi LICENSE WO RS' CO PvSAT�Ot���iCI A�?� 30 i <br /> TT IV- 6/22/99/sign bkpg/,VtIW1 <br />