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08/08/2001 16 05 2894683433 FIFTH FLOOR PAGE 02 <br /> - _ VVLL PERMIT APPLICATION FORM UNIT IV <br /> O1ectNod „ 134AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> SI'T ,pE� BF ENVI ONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> Weber, Third Floor, Stockton, CA , 95202 <br /> 2 3-4_,9_6_ (209) 468-3450 <br /> N -REFUNDABLE PERMIT EXPIRES Y YEAR FROM DATE ISSUED <br /> AP910c3t an ss hereby made to Sart Joaquin County for a peanut to coastrtrd and/or rnsrall the work descrbed This application is made in cornpbance with <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standanls of San Joagwn County Public Heratth Services Envlrpnmental Health Drvrsron <br /> ' 1.. C ass:sssors <br /> WELL Location 1�Do Mo,re.l�. Court Cross Street �a1MVMFJt�I-a-Q,cay J�C•��� Zip Parcel# r <br /> PROPERTY Owner Sa6aI Sy C1t Zip 52IS-Phoneo <br /> C 57 Contractor EKJ14 +-tll`_fit Address., t7p,.►Q!( __ _ Crly_Lk Phoneir �925�3l3'S <br /> Czn,ultant i Sub Conlraclor C&vA%1"^2. 6'`ytv-ovkr tL3L1IAddress ZZo Dem-IC4v_.s_SL_ City Sdn4M2L Lrcl Phon.LC1n_)9�5-4bso <br /> GIs Coordinates X Y Township Range Secuon <br /> WORK TO SE PERFORMED <br /> va EW WELL I BORING(CPT GEOPR06E HYOROPUNCH HAND-AUGER OTHER`) 3 OESTRUC70N(Choose type below) <br /> VT9OIL SCRING 9 SE-1 Cnd SQ-y: O OVER-SORE <br /> Q WELL At Q PRESSVRE GROUT <br /> '[]cher <br /> C'wtMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE COWSTRUC-LION SPECIFICATIONS <br /> 0NITORING a HOLLOW STEM DLA. OF eOREH0LE 2" MULTIPLE CASINW7 0 YES Q NO WELL CASING DIA <br /> TRAGTION 0 AIR t-iAmMEFVpRrVEN CASING THICKNESS 1.4A TYPE OF CASING p STEEL 0 PVC Q OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TRZMIE TYPE TO BE USED a AUGERS QHOSE <br /> Q AIR SPARGE a-1:rU5H POINT GROUT SEAL PUMPED O Yes [)No (N OTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> OrSbIL BORING Q HAND AUGER APPROX BORING DEPTH (10z a BOLTED TRAFFIC BOX or CI STOVE PIPE <br /> S OTHER CONDUCTOR CASING PROPOSEDZ (RYES, Gst specificanom htre) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby ctirtlfy ihet I have preoared WLs appdcanon and that the work well be done in aroanlanee wth San Joaquin County Ordinances State Laws and Rules <br /> and Regulanons of The San Joaquin County Homeowner or ticerised agerifs signature cerlrfies the following. 't curnfy that rrr ihopefformance of the work <br /> for which TATs permit is issued,I shall nor employ persons subject to WORKMAN S COMPENSATION Caws ofCalifornra Contractor's hinng or sub- <br /> contracting signature cert.ftes the following -1 Cerrify that rn the performance of the work krwhrch this parmlt rs issued I shall OmPloy persons subject to <br /> VVORKMAArS COMPENSATION Caws ofCalrfamra" <br /> THE APPLICANT MUST CALL 48 NRS IM ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Srgnod: 1-rtle _ I e Date <br /> SEE <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 0 t <br /> l!� DEPARTMENT USE ONLY <br /> ApoliCatton ACcepted By Date issued A <br /> Grout Inspection By Date Final Inspectronl8y1 Dare <br /> Oestrucrlon Inspecsron By Dale <br /> COMMENTS l CONDITIONS <br /> COUNTING ONLY AlDtt FACS <br /> FE CODES FEE INFO AMOUNT REMITTED CHECK#/CASN RECFIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> a -�?o <br />