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WEL[ 'ERMIT APPLICATION F( 'IM UNIT IV <br /> U <br /> _ r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) , <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 dN <br /> (209) 468-3449 <br /> HON-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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 'r 6a5t / Assessor's <br /> �, <br /> WELL Location r1K1 sltgA Cross Street 0 City C�7� Zip Parcel# � '/�•�Z <br /> PROIPERTY ownb7—�� ���T 1 Z t Address City • CZiR fm�lhone ?Zi <br /> I1lie /n! �l C-57 Contractor Address �_CityId3ZipuwLic# Phone# 0 0 <br /> ConsultantISubContractor V� Address `� i Lic# Phone# -2f o <br /> GIS Coordinates:X 'Y Tows ship I N Ranged Section <br /> t <br /> i WORK TO BE PERFORMED <br /> b W WELL 1 BORIN (CP ,GEOPROBE, YDROPUNC HAND-AUGER,OTHER-) d DESTRUCTION(choose type below) <br /> I TTTT &ZOIL BORING Q OVER-BORE <br /> 0 WELL# Q PRESSURE GROUT <br /> 'Other: Of I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE ^Z MULTIPLE CASINGS?0 YES NAO WELL CASING DIA;Ua l <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS^P�- TYPE OF CASING: <br /> I 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS X-IOSE <br /> ' AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> lf OIL BORING G HAND AUGER APPROX. BORING DEPTH ! <br /> ` '�OTHER: THER CONDUCTOR CASING PROPOSED? --(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: 'Y certify that in the performance of the work <br /> 1 for which this permit is issued,1 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, 1 shall employ persons subject to <br /> if. WORKERS'COMPENSATION Laws of California.' <br /> E APPLICANT MUST.CALL 48 WORKING HRS IN.ADVANCE FOR ALL,REQUIRED INSPECTIONS. <br /> i <br /> Signed x UA4itle R19 �30� Date Z D <br /> 1 ' <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY � <br /> . 1 <br /> Application Accepted By Date lssued '!' Qy Area D <br /> dx I <br /> I. Grout Inspection By h Date Final Inspection By Date_. <br /> Destruction Inspection By Date <br /> I <br /> COMMENTS 1 CONDITIONS: <br /> 1 <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> S # 003/3 <br /> GSTLICEHSEDC4N' AC"TOR=II+iTST SIGN LESW;� 5'± Q11E' SA` ION I3CiA ' ' <br /> i UNIT IV-6/23/99/sign bkpg/MI <br /> E . <br /> I <br />