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06/20/2000 09: <br /> r--` UNIT IV <br /> El� rERf�,IT APPLICATION F <br /> llV <br /> n������� _ ENVIRONMENTAL SCIENCE ASSOCIATE! <br /> ln� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> JAN 0 4 2001 ENVIRONMENTAL HEALTH olVISION (PHS-EHD JAN p 3 2001 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209)468-3449 <br /> PERI.AIT/SERVICES ►��p ff`` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I�cadon is made in CvmpM�lit�lt/�(A <br /> Application is hereby made ro San Joaquin County for a permit to construct and/or install the wormy desdesk Health <br /> This ice Assessors <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San <br /> Joaquin County Public Health Se 7 Environmental Heal•,.Division. <br /> o-Oa <br /> ',1 �p,nr�n vw� � _City ��Parcel# <br /> WELL Location �� LU s '—""'G "-��=Cross Street ajJ�Phoneti(309. <br /> a� �S4fI <br /> r 1 Address ���D ae��� 14 2 city ' nzp�— <br /> PROPERTY Owner un�Y 2�f5 t�NA-5, L ZI� tactl1�59a7Phone# <br /> p�G a� Address a In e,t..�,�c A-JP . City I'C <br /> C•5Y Contractor U t I�-' 0✓ Phone# -�`'�D <br /> ' 1 Address ��Ya►+►Cr icif <br /> Consultant/Sub Contractor EY�V:�Or`t`�e s+ t-13 0 <br /> —' C-C tH.Ce.At'J�.aiez ft��• ) Range Section <br /> .f ,Township <br /> G13 Coordinates:X <br /> WORK TO BE PERFORMED: <br /> ()DESTRUCTION(Choose type below) <br /> tk/ YDROPUNC HAND-AUGER,OTHER') U OVER-BORE <br /> NEW WELL/BORING{CPT.G�0011 BQRING i 13 t PRESSURE GROUT <br /> p <br /> WELL# <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .ES NO WELL CASING DIA�lh <br /> MULTIPLE CA [] <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE a l _ TYPE OF CASING: STEEL �PVC U OTHER: <br /> a EXTRACTION fl AIR HAMMERIDRIVEN CASING THICKNESS IJ TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br /> o VAPOR MUD ROTARY DEPTH OF GROUT SEAL nJ>� <br /> •dPUSH POINT GROUT SEAL PUMPED: ❑Yes �o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE - /b S Q BOLTED TRAFFIC BOX or []STOVE PIPE <br /> `SOIL BORING E HAND AUGER CONDUCTOR <br /> BORING DEPT <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> (]OTHER: U OTHER-- — <br /> r CU L <br /> COMMENTS: o ( J <br /> NOTE: OFFSIT ORINGS REQUIRE AC,CEC SaOR E SaCROACn oaquin CHM ountyo�nante R tl eTLaws and Rules ig`a tt- <br /> _ g.,, performance of the work 9 <br /> 1 hereby Certify that I have Prepared this aPPliCation and that the wont will lie dsignature certifies theonecertffy �I <br /> Sub- <br /> and Regulations of the San Joaquin County. Homeowner or I ,bjedcl6o WORKERS'COMPENSAf770fJ Laws of Ca farrria�' Contractor'srs'sub subject to 1�' <br /> for which this permit is issued,l shall not employ per <br /> sons contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued.)shall vmploY p <br /> WORKERS'COMPENSA77ON Laws of Ca/,Yomia." � <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTION <br /> TideiCompany�y ��"� <br /> Signed x a <br /> s Date rneyl-bpC.i�CT �v2.)< <br /> Print Name �r��eY5 t 'QLISaZ)10 g <br /> SITE FILE ADDRESSNVORK PLAN DEp° MET USE ONLYL=- <br /> Date Issued_j <br /> Y� Date — <br /> Application;�Acceepted By to Final Inspection By <br /> Grout InspDate <br /> DestruQion Inspection 8 <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> CHrE]f CuK# <br /> RECD BY DATE PERMIT!SERVICE REQUEST p INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> �JO( <br /> -oil111 .3 0 <br /> _ ter of Authorization to sign permit,Encroachment doc(s). <br /> C-57 exp,WC/Waiver C-57 Let <br />