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WELTPERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (" ., 9520 D") FILE <br /> 304 E. Weber, Third Floor, Stockton, CA., 45202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construe and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title.C apter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ,�l� p Assessor's <br /> WE'!Location �'""•' /V• Cross Street lauri� City j>)CKrn,v -Tip 952 Pansi6 <br /> c/o Pµ<JOAV rT 9r2o} <br /> PROPERTY Owner f"-z _ Atltlress 774 _/rNceui C6�+?c� City fTxr>n.v Lp Phone#209 V,7-f- 9210 <br /> C-57 Contractor SECTILv., ie.mvnw Address LJIr G.li�u..r �,�. City �7r &rN z:p 9S ruc#fmz86 Phone&Z69 y!S'8F/L <br /> Consultant/Sub Convactor«Q r rF Address 1960 Ae Aru -;- 127Vl�-City�r� VEC66Lcs N n Phones f/o 65"z-`/J'rD <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL I BORING(CPT, GEOPROBE. HYDROPUNCH. HAND-AUGER,OTHERD - - 0 DESTRUCTION(choose type below) <br /> '"0 0 SOIL 90RING s / Wt�l p OVER-80RE <br /> �ffLLx f`f >o u�+w-DZo( y } PRESSURE GROUT <br /> z �., nib=A7 r /Sw2tr) �� <br /> •Other f✓ E col " mi n G n7•l SUl O?f _ — <br /> COMMENTS: <br /> Tr°E OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS H <br /> 0 .MONITORING ZHOLLOW STEld DIA.OF 30REH01= 1L" MULTIPLE CASINGS?0 YES _�rNO WELL CASING OIA: y <br /> 0 EX T RACTICN 0 AIR HAMMER/DRIVEN CASING THICKNESS rCFI 1/0 TYPE OF CASING: 0 STEEL_,t;,VC 0 OTHER: <br /> j^1APOR 0 MUD ROTARY DEPTH OF GROUT SEAL G r T REMIE TYPE TO BE USED: 0 AUGERS -afics:01116 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. 30RiNG DEPTH $6 l 0 BOLI cD TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: CONDUCTOR CASING PROPOSED? (if YES.list specifications nere): <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 clone 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 WORKMAN'S COMPENSAT70N Laws of Cal7fonha." Contractors hiring or sub- <br /> cont, cting signature cues the folloxnng: 1 certify Nat in the pedormance of tie work for which this permit is issued.I shall employ persons subject to <br /> WCRKMAN'S COMPENSA77ON Laws of California.' <br /> I HE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR-� �`• ALL REQUIRED INSPECTIONS. <br /> Signed x G�! o �i^i �a-mD r�Y"�r..l Title /TF f�?ipEe7' /' e. Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED / <br /> �_ DEPARTMENT USE ONLY <br /> Date Issued l ap <br /> �� Area Dw <br /> Application Accepted ey_ __ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date - - n <br /> COMMENTS/CONDITIONS: -C/�OT a C7- �< <br /> FACS <br /> ACCOUNTING ONLY: AIl',Y. I I <br /> ?E CODES FEE INFO I AMOUNT REMITTED CHECKs1CASH RECEIVED BY DAT <br /> _ I� PERAArr/SERVICE E REQUEST NUMBER INVOICE <br /> �Ro I SVS I 155 IISR# l i <br /> UNIT IV-5/99/MI - <br />