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• - WE lPERMIT APPLICATION FuRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 <br /> /Development Title,,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> �JI�I' �� V>�i tl'�1�1 GGA l, /q Assessor's. <br /> WELL Location Cross Street e City% � Zip q-/_� Parcel# <br /> CF(10Ir %� <br /> c _ f <br /> PROPERTY Owner � � � A/ddaajriess, p4Vi �' i� Y�/E'J�-S City<� p e .�Zip 'Phone#® <br /> C-57 Contractor 811 ) � -yCyeddress I"� �VL+ �t jjU (�f Cityip /`�ZG # hone# <br /> Consultant/Sub Contractor !1 Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> [�qEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OOIL BORING# 0 OVER-BORE <br /> DWELL# 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rjA <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 rt MULTIPLE CASINGS?0 YES,,B-110 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE �USH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ROIL BORING 0 HAND AUGER APPROX. BORING DEPTH 4L 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? I\Q�(if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 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 wort:for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPE T WORKING HRS IN ADVANCE FORK ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company <br /> Print Name Date <br /> SEE SITE MAP IN UNIT _lV WORK PLAN DATED: �( • � <br /> DEPARTMENT USE ONLY / [ <br /> Application Accepted By a�aDate Issued ! �� Areav� <br /> Grout Inspection By Date Final Inspect4 By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a'el.o0_1 5 oriSR# Do ;-�--7 X1 <br /> 1/18/2000 <br />