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w <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> r <br /> SAM .fOAQUiN COUNTY AlU.THLIC <br /> f�N S ON (PHS-EMD <br /> SERVICES I <br /> ENVIRONMENTAL HE <br /> 304 E. Weber, Third Floor, Stockton, CA., 98202 <br /> (209) 468-3449 <br /> IRE i YEAR F DATE I SUED <br /> 1�0 •REFLINDASLE iicaQan is made in compliance with San <br /> Application is hereby mach to San Joagdn County for a permit to construct andlor install itis work de9crit>ed. This app i <br /> Assessor's `�Q <br /> Joaquin County Development Title.Chapter 9-7116.3 and.tt,e Standards of San Joaquin County Pudic Health Services:Env�rornn Parc�e#altll Olvis on. <br /> qD�2 W 7u�ef _Cressstrae3t city "15 zip ? <br /> WELL Lac-Allon !1 2 <br /> )9L Address Z City A Zip9SPhone# i <br /> PROPERTY Owner G <br /> WA Q 'S" y l `1a !t�City P Zip Nva Shane# <br /> C•57 Goatra:for ���l r dress /7 O+ � Pltane# <br /> ��-Lic# <br /> Consultant r Sub Contractor _RSC —Sectlon� _— <br /> .Township 7 <br /> GIS Coordinates:x <br /> W RKOBE PERFORM : <br /> q DES?RUCTION(dimse type below) �' + <br /> SAVV WELL I BORING(OPT,G6OPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE <br /> U SOIL BORING 9 0 PRESSURE GROUT <br /> p'[YELL# 6 <br /> -Othen e <br /> COMMENTS: <br /> TION >> <br /> TYPI"pF LL IHSTALLATI N PE CONSTR CTI i eFS ONO WELL CASING DIA: <br /> 10NiTORl1JO []HGLLt]'N STEM DIA_OF BGREHOLE�—MULTIPLE CASINGS? <br /> TYPE OF CASING'. #STEEL 4 PVC D OTHER:_$, <br /> Q EXTRACT''+ON a A!R HAI`UER/DRIVEN <br /> CASING THICKNESS . TREkRE TYFE TO SE USED: (]AUGERS CHOSE <br /> []VAPOR a V.UD ROTARY DEPTH OF GROUT SEAL <br /> f <br /> fl AIR SPARGE Il PUSH PUNT C3RO17T SEAL PUMPf7: es p/o (NOTE: MAXIM FREE-FAL <br /> R BQX or(]DEPTH <br /> O E P,PE3a'] <br /> b SOIL BORING 0 <br /> HAND AUGER APPROX.BORING DEPTHjQeq _Il BOLTED <br /> I]OTHER: HE;R� f NCIUCTOR CASING PRCPOSED7r�e� ca <br /> (if YES,list apeeifl 'ions here); <br />` 7 ' <br /> f COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hateby cer ify that I have prepared itis appiicatipn and that the work w,l!be done In accordance with San J a vin County Grdlnances,State Laws,and work <br /> and RegUlations of the San Joaquin County. Homeowner orlicensed agent's si Mature cefGf!es the following: i certify that in Lireparfarmance of Ctrs work <br /> for which this permit is issued,r shall not employ persons subject to WOFdKERS'COMPENSA770M Laws of Calftrnla.^ Conimetor's hiring or sub- <br /> pantreding signature cert'tras the following:T uertilk that in the perfo mamas of Cha mark for which this pem7ft is issued.1 shall employ Pa-sons subfact tO <br /> WORKERS'COMPENSATiCN Lavrs of Galfftimla,. <br /> "CALL THE UNIT N INSPECTOR 4$WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x <br /> � .ritielcornDarly V" � ut' <br /> Print Name Q 1 L' Date <br /> SITE FILE ADDR [WORK PLAN DATE: <br /> DE ARTMENT U E O LY <br /> Date Issued � �^C7 =' Area <br /> Application Accepted ly Gats <br /> Grout Inspection gy Data Final inspecdorr By -- -� <br /> Destruction Inspe�an By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACGGUNTINGON4Y: AID# r_ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REOUESr$ INVOICE <br /> C-57 exp.,WC/waiverC-57 Leiter of Authorization to sign permit Encroechtnet-lt doc(s). 5/17/00 <br /> £d 3� +d iJ00� H1�I� EEVEE9b6©Z 2E:9L 000z/EL/Z0 <br /> I <br />