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Ij <br /> PERMIT APPLICATWI� UNIT IV <br /> WELL Dr4ViRONUI,ENTAL HEALTH <br /> SAN JOAQUiN <br /> COUNTY PUBLIC 1 E19A&14�94vg5 hu COPY <br /> ENVIRONMENTAL HEALTH DIVISION {PHS-EHD} <br /> 304 E.Weber, Third Floor, Stockton, CA., 952025 � <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 andlar install the work described. This application is made in compliance with <br /> San Joaquin County Developmen Tdle,Chapter 9-1115.3 and the Standariilof San Joaquin County Public Health Services,Envi%nm teal Health Division. <br /> _ .w t <br /> WELL Location <br /> � UST r �. Cross Street Cit Zip g52 _Parcelit <br /> ( A Address r City�ti Zip QC Phone 5l Z6-64 <br /> PROPERTY Owner AA G 7 7��1 phon o <br /> �j Address 't1 x ��� _Cit f0 'E ZIp RLidl r 'ZO 1 1 <br /> C-57 Contractor ~T <br /> r ~T- <br /> Consultant!Sub Contractokl�, <br /> r `QAC. Address Zt7z� C. J�City�7o1- —Lic# f Phon 7d•1 "»75 <br /> GIS Coordinates:X <br /> ,f ,Township Range Section <br /> WORK TO BE PERFORMED <br /> E� <br /> IN WELL I BORING(CP OPRO , YDROPUNCH,HAND-AUGER,OTHER') $ DESTRUCTION(choose type below) <br /> l� 5 BORING #J OVER-BORE <br /> PRESSURE GROUT <br /> WELL# <br /> 'Other-, <br /> I` 1 <br /> COMMENTS; e- <br /> Artit R 4 <br />[ TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING p HOLLOW STEM DIA.OF BOREHOLE Z)L2 " MULTIPLE CASINGS?0 YES Q NO WELL CASING DVA: <br /> Q EXTRACTION 13 AIR HAMMERIDRIVEN CASING THICKNESS A` TYPE OF CASING: 13 STEEL Q PVC Q OTHER: <br /> VAPOR � I�J UD ROTARY DEPTH OF GROUT SEAL;• G TREMIE TYPE 70 BE USED: p AUGERS []HOSE <br /> 0 AIR SPARGE .PUSH POINT GROUT SEAL PUMPED: 0 Yes (NOTE. MAXIMUM FREE or <br /> DEPTH 130'} <br /> SOIL BORING YYEl H`HAND AUGER APPROX.BORING DEPTH � - Q BOLTED TRAFFIC 80X or Q STAVE PIPE <br /> a OTHER:___-----U OTHER— CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here): <br /> i <br /> COMMENTS: `� 4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 7 at the work will be done In accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> hereby certify that I have prepared this appilcation and th <br /> and Regulations of the Son Joaquin County. Homeowner or licensed agent's signalure certifies the following: "!certify Char in the performance or the work <br /> for which fhls permit is issued I shall not emplay persons sub]00 to WORKERSCOMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signalurd certifies the fallowing:"f certify that in the performance of the world for which this permit is issued,I shag employ persons subject to <br /> COMP SATION Laws of Carf€srnis.' <br /> woi�xFRsA � ;� IRE / <br /> Sined x Title/Company <br /> 9 <br /> Print Name z Date Z O <br /> 'S�ZSa� <br /> DEPARTMENT USE ONLY O <br /> Application Accepted Ry <br /> Date Issued �'�` Area <br /> Grout Inspection By Date �; Final Inspection By Date <br /> Destruction Inspection By Date <br /> s <br /> COMMENTS/CONDITIONS:_- - CJ <br /> FACCOUPMNG ONLY: AID# <br /> CODES FEJTINFO A1410UNT REfiIIITTED CHECtt* Il RECD BY D��PEM�ITIRVICE REQUEST it INV501 Z � zc)oo � <br /> 70 30V8 N00-1-� HIJIA E6bEe9V60Z TE VT 000Z/9Z/t10 <br />