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WE• PERMIT APPLICATION11ORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> / /,'�,,� .,,,., I A G Assessor's <br /> WELL Location ZO 5r 6v, ryft'.C-IwrVG�+"' rTlls��,Cross Street City / V` Zip Parcel# <br /> PROPERTY Owner 4ft-f-/�A(vluw&r**,L/`��,1gd31€,4`sl SCrt-(pyll City sic- Zip / Phone# <br /> C57 Contractor111161mewl r/&alrrc�r.f6ddk'9Y 7�N•u✓�SG�/W% coy S)L!!C7CR/Zip�9 as uc#(/�QZ7'Yhone# 1147-1&d,6 <br /> r( <br /> Consultant/Sub Contractor SItYVfE Address 15 l� City SAS" Lic# 7 Phone# <br /> GIS Coordinates:X , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> WNEW WELL/BORING(CPT,GEOPROBE, HYDR UNCH, HAND-AUGEB,OTHER-) 0 DESTRUCTION(choose type below) <br /> V SOIL BORING# 0-I 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 4 MULTIPLE CASINGS?0 YES O NO WELL CASING DIA:= <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^N/D TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER APPROX. BORING DEPTH M/O r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED?_� (if YES, list specifications here): <br /> COMMENTS:— <br /> NOTE: <br /> OMMENTS 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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICANT MUST ALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title (/� Date ..3/len SEE SITE MA I UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY �i1_ <br /> Application Accepted ByA4Date Issued Z _ � DCCCTT7 <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2553 � 2-24 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />