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LULU <br /> WELPERMIT APPLICATION IRM UNIT IV <br /> c =U <br /> r� <br /> �c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> W� ENVIRONMENTAL HEALTH DIVISION ("PHS-EBD") <br /> (L-0 z 304 E. Weber, Third Floor, Stockton, CA.,. 95202 <br /> LU (209) 468-34$0 <br /> LU NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> Assessor's <br /> WEL:.Location 3 G +t 132— Cross Street City S _Zip Parcel# <br /> PROPERTY Owner I� -Addressed! I CityPc� �G j Zip hone#Ly G� <br /> C-57 Contractor t+ (4OA4::.e Address `/-Z IAJ I. 1 S ity fj Phone#/�7f/�� <br /> Consultant]Sub Contractor ddress X33 CitYti Phoned+�lL� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW <br /> WELL/BORING (CPT.GEOPROSE,HYDROPUNCH.HAND-AUGER.OTHER-) Q DESTRUCTION (choose type below) <br /> 0 SOIL BORING T FIL <br /> 0 PRESSURE <br /> 0 WELL# � PRESSURE GROUT <br /> Wither. <br /> COMMENTS: <br /> TYPE_OF WELL CON TRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW ST'cM DIA. OF 30REHOLE MULT IPL= CASINGS? 0 YES 0 NO WELL CASING DIA: <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEL Z4vC a OTHER: <br /> 0 VAPOR �]MUD ROTARY DEPTH OF GRCU T ScA'_ TREMIE TYPE TO BE USED: 0 AUGERS OHCS <br /> O <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: M XIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH o O OLTED T FRAFFIC BOX or 0 STOVE PIPE <br /> O OTHER: CONDUCTOR CASING PROFOS=_D? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that I have prepared this application and that the worx will be done in accordance with San Joaouin County Oramances. State Laws. and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the lollowing: "I certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sup- <br /> ;ontracting signature certifies the following: 'l cerlify that in the performance of the work for whicn this permit is issued, I snail employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomra.' <br /> gyp) THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Si ned x "" Title_"L"��o�I"S� - --Date l 3! �VOtJU <br /> 9 <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Aooiicatio>1 Accepted Sy Date Issued 1 1 (70 Areae <br /> Grout Inspection By C> � a Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> FAC; 1� <br /> ACCOUNTING ONLY: AID# 1 <br /> a <br /> E355'10 <br /> OES I FEE INFO AMOUNT REMITTED CHECK#!CASH I RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> �9: k l`I Z � � II no l p <br /> 'JNrT IV- 5/99/MI <br />