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N -- <br /> I <br /> WELL PERMIT APPLICATION FORM` ., <br /> 0AV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE C3i yO <br /> ENVIRONMENTAL HEALTH DIVISION ( PHS-EHD) �Nj ��� `s� <br /> 304 E . Weber, Third Floor, Stockton, CA. , 95202 ��O <br /> (209 ) 468-3449 �qu yfi <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 mala in com llance ith <br /> ;an Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division . <br /> I n � I 4vt Assessors <br /> NELLLocation 41 ;2S Ld.den L J Cross Street 1r1r/ dar'-ud City Zip Parcel# <br /> 'ROPERTY Owner idir:t w<1bE' <br /> Address_1.;5A . Phr Iac�Ai6�V <br /> Y-/¢ City AmfgTCA Zip 9/.794 Phone# 509 -SA? - S31LYJ <br /> II <br /> ;-57 Contractor V. kl U.Gfli I@, t TA�Address P/ /©. 667( 5/ City +o i Zip 9!5(.57/ Lic# 710SCJY Phone# <br /> :onsultant / Sub Contractor IQ 'dY, , FfiIr: &d M&tk1Address ?. Q , r 339 City �Lic# Phone# ZQ- ;119- ,951Irn <br /> ; IS Coordinates; X., Y., Township Z $ Range 1i F Section I <br /> VOORK TO BE PERFORMED — --- <br /> (NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") p DESTRUCTION (choose type below) <br /> p WIL BORING # \ 0 OVER-BORE <br /> VKVELL ih. S f/r;.,� /H.LJ-��f 9J /0 Cekd it <br /> J\ ❑ PRESSURE GROUT <br /> Other: <br /> :OMMENTS: <br /> 'YPE OF WELL 'INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ! <br /> rOhONITORING V 0LLOW STEM DIA. OF BOREHOLE__ MULTIPLE CASINGS? 1] YES JJ<O ''LLWELL CASING DIA <br /> I EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SCA </0 NT <br /> dSYPE OF CASING: [1 STEEL frfVC 1] OTHER: <br /> I VAPOR 1] MUD ROTARY DEPTH OF GROUT SEAL 3 r TREMIE TYPE TO BE USED: 11 AUGERS 6W5SE <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 309) <br /> SOIL BORING 1) HANDAUGER APPROX. BORING DEPTH 10 " <br /> fff3OLTED TRAFFIC BOX or Q STOVE PIPE <br /> I OTHER: ❑ OTHER CONDUCTOR CASING PROPOSED? <br /> ( if YES, list specifications here): <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 /> nd Regulations of the San Joaquln County. Homeowner or licensed agent's signature certifies the following: "i certify that in the performance of the work <br /> 31r which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br /> on"cting signature certifies the following: 7 cCrfify chat in the performance of the work for which this permit is issued, I shell employ persons subject to <br /> VORKg sofCaliforma <br /> ERS' T IIO� LayyUST ICALL 48 ;VQbR)U(VG HRS TNI A,b/VAI,A�NGEOR ALL REQUIRED INSPECTIONS . <br /> ;i nedx 7.�h(r►' SCI dl( r /1 / Date 3 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED : <br /> DEPARTMENT USE ONLY �/ <br /> .pplication Accepted By Dale Issuetl /— 7 O Area a ZS 0 <br /> ;rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTSf ION CJS igr/L. 410rws- <br /> w��Z, <br /> ACCOUNTING ONLY: <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3sa / 99 - r - 393 Co /- 7- 00 <br /> C$ 5ZZIGEI� SW C0N'TkACTQA AU, S'TSTSN[1LJCENSLt-Z( ) KE12S' CCSIVIS £NSATXON AEGLARAtXON <br /> )NIT IV - 6/23/99 /sign bkpg/MI <br /> � . i <br />