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WEL PERMIIT APPLICATION IF RM IT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTA:0HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber,J!fil,rd Floor, Stockton, CA., 95202 <br /> ' (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES F YEAR FROM DATE ISSUED 1 <br /> Application is hereby made to San Joaquin County for a permrfito 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 /> Assessor's a <br /> WELLLocation CEM E TE RY LANE Cross Street KAP V 1 RG- City SIOCKTO N Zip 9520 Parcel# I� -700�0Z i <br /> SAN TCAQVIN {x:09} li <br /> PROPERTY Owner Cf Tit O L(G G E M E T qY Address � d• I3 01( I�3}`. city S i O G 6 TO N Zip 95ZO I' Phone# !I ro b-_ r. <br /> GRF.Cr(T pRILLINCrdV t MA RTINE 7_, <br /> C-57 Contractor Tl 5T(NG, TNC, Address 9S"(3".1ia1WE RV. City,,, GA _zip94553Lic#65640}Phone#313- 58C0 <br /> T-05EFR RAMhGI- `',; :;i' P.t7. ROIL ? G9 R.G. .. (9ib)II ' <br /> Consultant 1 Sub Contractor_R k M h Cr E I=R V(R O N:'Address A(\t G i k 0 ESI V RI A City 9S(i 133 Lic# 52 S ro Phone#_3.5 4- �-2 59 <br /> i is <br /> GIS Coordinates:ri ange <br /> WORK TO BE PERFORMED i <br /> NEW WELL/BORING(CPT, GEOPROSE,HYDROPUNCt• ,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) i <br /> I SOIL BORING# G -:Ii '.i _— ©'OVER-BORE il[ <br /> 0 WELL 2 i` 0',PRESSURE GROUT <br /> 'Other. r ' <br /> I <br /> COMMENTS: 1 fl K'S I T E ;C P 1i t)li 1 N G l f <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA'�6+ 8012EHOLE 1.5 {�: MULTIPLE CASINGS?0 YES I NO WELL CASING DIA: i-(A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CA61NG,THICKNESS NA TYPE OF CASING: 0 STEEL_ 0 PVC:! 0 OTHER: t4A_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF,GROUT SEAL '�T D"100 TREMIF TYPE TO BE USED: 0 AUGERS DHOSE I <br /> p AIR SPARGE IIIPUSH POINT(C PT) GROUT SEAL PUMPED: ()=Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> d SOIL BORING C HAND AUGER APPROXI BORING DEPTH 10 0- F t 0 BOLTED TRAFFIC BOX or 0 STOVEPIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? Nfl (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS'REQU,IRE ACCESS OR ENCROACHMENT PERMITS! l <br /> 1 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 i <br /> and Regulations of the San Joaquin County. Homeowner orrlicensed agent's signature certifies the following: "t certify that in the performance of fhe work <br /> for which this permit Is issued,1 shall not employ persoissirbject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting sianature certifies the fol[owina: 7 certify that in fhe performance of the work for which this permit is issued. I shall employ persons subject to 11 <br /> WORKMAN'S COMPENSATION Laws of California." t <br /> 0TH A LIC UST CALL�46 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 4771-14 <br /> Signed x s� i Title <br /> "a�+- . <br /> i <br /> SEE SITE MAP IN UNIT IV" WORK PLAN. DATED <br /> AF AIL i4 2oQo �I <br /> .DEPARTMENT USE ONLY <br /> Application Accepted B Date Issued L90 Areas "-- <br /> Grout Inspection By c's Date '" 0( * Final Inspection By <br /> Destruction Inspection By ''IDate 't <br /> COMMENTS!CONDITIONS: 7 <br /> FAC# <br /> ACCOUNTING ONLY: AID# § P, <br /> PE CODES FEE INFO AMOUNT REMITTED CHE 3,# ASH RECEIVED BY DATE,: -PERMITISERVICE REQUEST NUMBER INVOICE <br /> a (.: Ilk <br /> r , <br /> UNIT IV-6/1/99/sign bkpg/MF 1 <br />