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a ►moo iy:.�� ie:�eirrr rrturn <br /> WELL PERMIT APPOC TION FORK! UNIT IV <br /> fi.. �f Fri � r <br /> i:. SAN JOAQUIN COUNTY PUBLIC HEALTH SiR1/,ICES} r?t ri€'_ dfi <br /> ENVIRONMENTAL HEA DI ISIQN (PHS-EHD)"' ' ' <br /> 344 E. Weber, Third Floor, S#o kton, CAl ft2.P? APP 11: 54 <br /> (209 '468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y R FROM DATE ISSUED <br /> Application i$hereby made to San Joaquin County for a permit to construct andlyr install he work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of SaWoa uin County Public Health Services, Environmental Health Division. <br /> �^ w eM iS (�0-09 Assessor's <br /> WELL Location aam i5 AD Cross Street F! 6jr n ity S ^JziA Parcel# i� 2 <br /> PROPERTY Owner I�A�rxrx�! Fr h li r Address I f f r•City _ Zip DPhone# (6,zA A Y'7 775 <br /> C57 Contractor A. G, Address,100f IV, W1hon IW3-CilyS� 1�1�lZfp��SLidf�lY3 ZZ7Phone# Zc�" �rCO{p <br /> Consultant ISub ContractorC0Ili ItEPA PAS Aaaress S E a 5 'c hQiM Lire r Z7 Phoneff7)V-99b'04/L <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL 1 BORING(CPT.GEOPROBE, HYD PUN H HA U EI� THER ) []DESTRUCTION(choose type below) <br /> - 0KL BORING# � _ � a OVER-BORE <br /> vOILL# a PRESSURE GROUT <br /> •Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> a MONITORING D HOLLOW STEM DIA.OF BOREHOLE Dl - ULTIPLE CASINGS?p YES-110 WELL CASING DIA: N/t9 <br /> Il EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS N TYPE OF CASING: 0 STEEL p PVC p OTHER: <br /> D VAPOR MUD ROTARY DEPTH OF GROUT SEAL Y2ffe,I JX TREMIE TYPE TO BE USED: a AUGERS .)R"'OSE <br /> D AIR SPARGE -�USH POINT GROUT SEAL PUMPED: p Yes Wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> A OIL BORING D HAND AUGER APPROX.PROX. BORING DEPTH EL* 'I]BOLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER: I'f OTHER CONDUCTOR CASING PROPOSED?Nile (if YES,list specifications here): <br /> COMMENTS: <br /> 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 aca rdanca with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature a riifies the following: 17 certify that in the performance of the work <br /> for which this parmlt Is issued,I shall not employ persons subject to WORKERS'C MPENSATION Laws of Califomfa." Contractor's hiring or sub- <br /> contracting signature certifies the following: V certify that in the performance of the work f w which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENS0.TION Lams of California.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVAN FOR ALL REQUIRED INSPECTIONS. <br /> r Signed x Title ° C �P 1 Date 9 <br /> SEE SITE AP IN UNIT IV WORK PLA DATED <br /> DEPARTMENT usE O LY 9 <br /> Application Accepted By �� � D to Issued 'F /�' „r- Area--- <br /> Grout Inspection By Date Fi of Inspection By Date <br /> Destruction Inspection By Date / <br /> COMMENTS f CONDITIONS: of (Z 2 <br /> ACCOUNTING ONLY: AID# FACfk <br /> PE CODES FEE INFO AMOUNT REMITTED C EEC CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> SR# <br /> C-57'LICENSED:CONTRACTOR'.MUST'SI.614'�:LICENSE&)FRKEP,.S'.:COMPENSATION DECLAARATION <br /> UNIT IV-6/23/99 lsign bkpg/MI <br /> m <br />