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VlY,,.,LL PERMIT APPLICATIO>iiiiiwFORM 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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> A Assessor's <br /> WELL Location./'0-]/ /(/_ Zlcu n S+% Cross Street Lbu i sc f+ve.CityA-g,n1ca Zip?, 33 to Parcel#a I-7 070 11 <br /> PROPERTY Owner/A;K4 G--_,i a n n ; Address 14n, E. t,,,ii e AA City AAv-ArtcQ Zip?S33L Phone#.20q-k.13-32 YS- <br /> C-57 Contractor' regia. br:l 1:..C Address-= I4ew2 QoaA City,6aZip d-S Lic# SI Phone1g2S--_?L?S -60 <br /> Consultant/Sub Contractora W%tr A EAyj `O,%y%enWAddress 11441 GSth S}_ Svc thCity NK V,.,\ct Lic# Phone#571)-yW3-®7co <br /> GIS Coordinates:X Y Township Range Section <br /> WOR <br /> KTO BE PERFORMED <br /> 04EW WELL/(ORIN CPTI26�HYDROPUNCH,HAND-AUGER,OTHER") 1]DESTRUCTION(choose type below) <br /> OIL BORING# S 19— []OVER-BORE <br /> WELL# (]PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING []HOLLOW STEM DIA.OF BOREHOLE A " MULTIPLE CASINGS?a YES []NO WELL CASING DIA: <br /> a EXTRACTION (1 AIR HAMMER/DRIVEN CASING THICKNESS /1/A TYPE OF CASING: []STEEL I]PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL /1A*e.-y1 TREMIE TYPE TO BE USED: []AUGERS [] <br /> HOSE <br /> []AP SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING Q HAND AUGER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or []STOVE PIPE <br /> Q OTHER: WETHER Ge <br /> M" CONDUCTOR CASING PROPOSED? A,1A (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 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 work for which this permit is issued,l shall employ persons subject to <br /> WORKERS'COJVPENSATION Laws of California." <br /> C-A"THE UNIT'1 INSPECTOR. 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed ���.. /C_v Title/Company <br /> Print Name Date <br /> , ; . <br /> DEPARTMENT USE ONLY <br /> Application Accepted By t[/ Date Issued it % <br /> 1l b C) Area Y`V <br /> Grout Inspection By _/M Date 7a Final Inspection 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 /> 0 <br /> 1/18/'2000 <br />