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1�-bl-lyyy 11J:17t3HM FROM TO 15592687126 P.02 <br /> WP <br /> 0 <br /> WPL PERMIT APPLICATION FORM UNIT IV <br /> SAID} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO-) <br /> 304 E. Weiser, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDAROM DATE I551.1ED <br /> ,applioation is hereby made to San Joaquin County for a permit to construct and/or install the work described_ This apptic:aWn is made in comPFanoe writs+ <br /> San Joaquin County peveiopment Time,Chapter 9.1115.3 and the Standards of San Joaquin County Pubric Heafth Servx es, Environmental eatttt.Dimion. <br /> WELL Location 21801 Wjm]a 4 120 Cross Street-ci-rn _..City T4rmlcn---To 95320 Parcel# x(15-2�7 <br /> PftOPLRTY OwnCrj�,�,�a�;�t3.J117�721� Address 21801 plc baW 12(1 City F�alrn �rag532n Phone#2Q9=8_19-357!; <br /> Address 25 7 FYt- St. Ctty ZIP�_�' Phone#5, -7 21 <br /> C-57 Contractof'�n„�i r� T a}-rtrai-ry-i�_ <br /> Consutiant/Sub Contractor TMniW TabaL Lies _Address 2527 EQt_- n St-_ City cL Li&__Phone# 559--268-70 <br /> GIS Coordinate,&X�37t.148/1D n . 191.19414 , .Township-- Range 8 E Section 36 <br /> WORK 70 sE PERFORMED <br /> NEIN WELL 113ORING(CPT. Gi_OPR08E,HYDROPUNCH.HAND-AUGER. OTHER- Q OE$TRUCTION (choose type below) <br /> Q SOIL BORING x Q OVER-BORE <br /> Q WELL# Mn1 1 Q PRESSURE GROUT <br /> 'Outer. <br /> COMMENTS: <br /> TYPE OVWELL CONSTRUCTION TYPE COIL";, 110N SPECIFICATIONS <br /> M PIA OF BOREHOL�.11 irrh.MULTIPLE CASINGS?EI YES JINO WELL CASING OtA A <br /> MONITORENG (HOLLOW STE <br /> EXTRACTION Q AIR HAMMERIORIVEN GASINC3 l H1CKN7=S$ G�� L](� TYPE OF CASINCa: Q''T EL E OCHER <br /> Q VAPOR Q MUO ROTARY pl:PTH OF GROU. SEAL 44' :. TREMIE TYPE TO BE USED AUGERS CHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED_ 0 Yes 1j No (NOTE: MAXIML!(VI FREE-FALL DEPTH IS 301 <br /> p SOIL BORING Q !1AND AUGER APPROX. BORING DEPTH $0 0 SOLTF D TRAFFIC BOX or a STOVE PIPE <br /> Q OTHER: <br /> CONDUCTOR CASING PROPOSED? (if YES.fist spec4cabons mere): <br /> COMMENTS: <br /> NOTE: OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS€ <br /> herebycert; that I nava prepared this application and that the work will oe done In accordance with San Joaquin County Ordinances,State Laws.and Rues <br /> certify p : "I cert( that in the erformance of t9te w•orir <br /> and Regulations of the San Joaquin County. Homeowner or @tensed agent's signature certifies the fOtlowing fy P <br /> for which Vrl5 permit/s Issued,t shat!not employ Persons subject to VMRKMAWS COMP15NSA77ON Laws of California." Contractor's hiring or sub- <br /> cantracting signature certifies the foltowtng: 'f certify that in!fie performance of me wore for which this permit 13 i55u9Q. I Shaft employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of CakyCv"*' <br /> THF:APPLICANT MUST CALL 48 HRS IN ADVANCE= FOR ALL REQUIRED INSPECTIONS. <br /> signed x Tine 0,cnir-u =gym ('FL1lT Dam 6/6/00 — <br /> SEE ��E MAP IN UNIT IV WORK PLAN. DATED <br /> OePARTMENT USE ONLY <br /> AppGodtiOn faCaptGd By 1<� nn�(rii t?ata I t-nued U ArAa�___ <br /> � n .r.r .. Date -> Finat InsOetdion!3y (� .+hA r'vt-t. Date L2, <br /> Grout Inspection By 'L--• <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITEONS: <br /> FAC# <br /> ACCOUN'nNO ONLY: AID# <br /> AE CODES FLEE INFO AMOUNT REMITTED CHECK#ICASN RECEIVED BY DATE PERMIT151ERVICE REQUEST NUMBER INVOICE <br /> 6 6 1 O D 3o90 1 <br /> �, <br /> UNIT TV-5/99!MI <br />