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�'` '� � <br /> WELIWERMIT APPLICATION F(OM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL t �rt <br /> (209) 468-3"9 0 R j G I NA[ <br /> San Joaquin County Development Tits.Chapter 5-1115.1 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ado �uy <br /> WELL Lnrr07' /oa TcJy <br /> l �ie-/'Ci Cross Street erI I,Ya City cSfdckt�T�l zW 5 i o 1PaametllAsse�di45-n go-050 6 <br /> PROPERTY Owner &VI-4f StOC k1`014 Address VeA-Lf✓a City Zip 95W1 PJ,03 52 16 <br /> C-57Contractor Cil yrL.L- Address 5195-47✓n1:Frk- 0/'city�RcW41 ver °9 Lic# Ph`c;;;##2oti`t -3 17 <br /> Consultant/Sub Contract-- ec.Y✓r-( rI/L Address 416S�i�r�o city cMhs-Llc# 5/z26�,hone#465-8-/1Z <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> QrNi IN <br /> /BORING (CPT.GEOPROSE,HYDRC2UMCti._HAND-AUGER_ OTHER-) 0 OFSTRUG71ON(choose type below) <br /> Q SOIL BORING# — 0 OVER-BORE <br /> a WELL# KP$4-1 0 PRESSURE GROAT <br /> 'Other <br /> COMMENTS: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS i1 <br /> MONITORING HOLLOW STEM DIA-OF BOREHOLE MULTIPLE CASINGS7'0 YES WELL CASING OIA:� <br /> Q EXTRACTION (I AIR HAMMER/ORIVEN CASING THICKNESS Sr jI 4-0 FTE OF CASING: 0 STEEL Z"r/C 9 OTHER: <br /> U VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL.t-Z O( TRE!dIE TYPE TO BE USED: GAUGERS a7FfoSE <br /> Q AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:,rtt 'es p Nc (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SCIL BORING 0 HAND AUGER APPROX.BORING DEPTH 1S I 00LTED TRAFFIC BOX or p STOVE PIPE <br /> g OTHER: fl OTHER CONDUCTOR CASING PROPOSEW-A2(�—(if YES,list spfta=ticns here): <br /> 75/ <br /> COMMENTS: Gell will be So o flA '04' Sfi Corrie✓e <br /> V eAA � f/in y- S&0 0-YCL , Jeri✓Is XOP PI! l -5 her l8rit Te .yt i Pte 1 614 V 1y-. fare✓n vcA <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and drat the work mil be dcne 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 ofthe worh <br /> for which this Permit is issued,I shag crow ampley persons subject to WORKERS'COMPERSA77ON Laws ofCaliforhia.- Corrtndofs hiring or sub- <br /> Contracting signature certifies the following:9 ceriify drat in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Calilania.' <br /> ���LtytyT,,HEE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. G <br /> Signed x JL�X/Y 7.n/ Title fi�Ll(n I V-P� -----Date C/r <br /> SEE SITE UMAP IN UNIT IV WORK PLAN DATED —((-98CC�Z�c /6�211 <br /> DEPARTMENT USE ONLY <br /> Applicauan Accepted ey Date Issued <br /> Grout Inspection By Date Final Inspection By Oats <br /> Destruction Inspection By Date <br /> COMMENTS/CONDRIONS: <br /> F ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH I RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> Z4ols ►�luJ `rte 00 9 L D/S9 6 <br /> UNIT rV-6/23/99/sign bkpg/MI <br /> 6root-99v (saz) <br /> Z0Z96 `-BYO `UO1AoO;S `JoOld P-J141 `1agaM '3 SOC <br /> .� (OH3-SHd) NOISIAIQ H174-2H 1V1-NEWN021IAN3 n I-Ia-r <br /> S301ANEIS H11V3H 0118f1d UNf100 kftt/Of t1VSz <br /> nl 1(Nn M0=1NOIJ-VOl-IddV i1W2:Gd -1-13M <br /> = r <br />