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• T V <br /> WELL PERMIT APPLICATION FORT AL FC \ <br /> lK( E±P"E d i lit. HEAI.IH JAN 14 2002 <br /> �.. „r:,,lr cFgV;CE SAN JOA4UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS EH � rLER-RYA!, <br /> .2 TI <br /> FEB — I PM 1' 41 304 E. Weber, Third 9)468 3449kton, CA., 9520 GFN=RAL CONTACTOR` <br /> lication is made in compliance with <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU <br /> yserviceEnvironmental Health Division. <br /> Joaquin Count for a permit to construct andlor install the work described. This app Assessor's <br /> Y <br /> Application is hereby made to San chapter 9-1115.3 and the Standards of San Joaquin Count Public Health 2o 2 Parcel# 139' <br /> San Joaquin County Development Title, P I � � city 5,1-o�2ip� <br /> E _Cross Street Cam 416'TI'S'' <br /> Yll^er 8788 C-lk60ove gl$ ' CityllkU�zip r62y Phone#__� <br /> WELL Location '7 r 707-3-f4-y3o0 <br /> oCal Addressi3 old+~3 S CitYR'o V�Z`p 9'�5T1 Lic#71" Phone#�� <br /> PROPERTY Owner ll p0 goX 36 916 -631-13°° <br /> 11 d Address "(_��� -1211 Phone#�— <br /> C-57GOntractOrV- 6� t•r 1 rso!1 ar Inf Id 1wOI7rl-ity �� <br /> D a,v�d or (,.v�Address� <br /> �- R . Section--- <br /> consultant <br /> ection� <br /> Consultant I Sub Contractor Range,�� <br /> 7ownship�� <br /> GIS coordinates:X__--- Y-- DESTRUCTION(choose type below) <br /> WORK TO BE PERFORMED U OVER-BORE <br /> U PRESSURE GROUT <br /> ,%NEW WELL I BORING(CPTI1 <br /> SOIL BORNG#DROPUNCH,B AND <br /> -AUGER,OTHER') <br /> 3Ay„ <br /> -Other: p WELL CASING DIA: <br /> COMMENTS: CONSTRUCTION SPECIaF1CATlON1NULTIPLE CASINGS?OYES yfN OTHER'. <br /> TYPES INSTALS DIA OF BOREHOLE PVC <br /> HOLLOW STEM 0 TYPE OF CASING: STEEL �. AUGERS <br /> iOSE <br /> U,MONITORING I �Q TR TYPE TO BE USED: <br /> U EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS 5a� <br /> U MUD ROTARY DEPTH OF GROUT SEAL_ STOVE PIPE <br /> U VAPOR <br /> GROUT! PUMPED: Yes USN.o (NOTES'. MAXIMUM <br /> EID TRAFFIC BOX_FALL <br /> rLODEPTH IS 30 <br /> 4AIR SPARGE OZONE 0 PUSH POINT <br /> 0 HAND AUGER APPROX.BORING DEPTHy rf YES,list specifications here):�� <br /> U SOIL BORING CONDUCTOR CASING PROPOSED? N <br /> U OTHER:_�U OTHER--- <br /> COMMENTS: <br /> OR ENCROACHMENT PERMIT <br /> DIRE ACCESS Joaquin County Ordinances,State Laws,and Rules <br /> NOTE: OFFSITE BORINGS REQ uin county11 certify r theparformance of the work <br /> 1 hereby certify that I have this application and that the work will be done in accordance with San Joaq <br /> to ersons subject to <br /> 1 shall not employ persons subject to WORKERS'COMPENSA710N Laws of California." Contractofs hiring or sub- <br /> prep-mo <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: ' <br /> for which 0sig permit er issued, <br /> contracting signature certifies the following: 'I certify that in the performance o/the work for which this permit is issued, I shall emp Y <br /> WORKERS'COMPENSATION Laws of Cali/omia." I r 3l(0-Z <br /> T APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL�EQUID ED INSPECTIONS. <br /> � q / _ : Titled [9L aS5 <br /> te <br /> Signed x YYY / <br /> SEE SITE MAP IN UNIT IV WORDEPARTMENT PLAN DATED: II� -7/01 <br /> Area <br /> -- <br /> Data Issued AI <br /> Application Accepted By ` - Date `} I I Final Inspection By <br /> Grout Inspection By ( Date <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED C SCK# b !1 �- <br /> 3 O I J 0O Y� <br /> C-57 LICENSED CONMRP,CTOR MUST SIGN LICENSE &WORKERS' COMPENSATION'DECLARATIO <br /> UNIT IV-6/23/99 /sign bkpg/ <br />