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WELPERMIT APPLICATION FRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 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 /> WELL Location ` ST �'`� �As/ f41t; Cross Street City '�DUc`c.I�C Zip gSc� Parcel# <br /> PROPERTYOwner&C-t d,u,�> MAPcA 7A4P4 Address qLQ� PE4S14tAf4r AtIL City.SZcrlt. TZip9S-.?b7 Phone#00 1f.76 -S�1aD <br /> C-57 ContractorA Addressilw5i d. WILSc.J WAY. CitySr&k74(-/ Zip9574s Lic#.(�9&27 Phone Zed Ql- Cdr <br /> t-c- <br /> R[- &M <br /> Consultant/Sub Contractor FMV(ffk?ice 9E Address3�i Vic. MIP--ALGMAS'+19CityAnlLic#�E62Z7 Phone#(71V)59E- 6312 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL/BORING(CPT GEO�.PROS HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL B ING# �'t� P--2- 2-3 a OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA. OF BOREHOLE Zr MULTIPLE CASINGS?a YES „(NO WELL CASING DI&M, <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 4,(LA TYPE OF CASING: 0 STEEL 0 PVC OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEALT6-rAt Pff1� TREMIE TYPE TO SE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: a Yes VNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> tSOIL BORING 0 HAND AUGER APPROX. BORING DEPTHS-- FIEk-i a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?_N//4 (if YES, list specifications here): <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 done 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, 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sut>- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APP LI-aSANT.MUST CALL:'48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x _ TitleSTAFF CTFOL061ST Date 08 -17-00 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED:. 241 Jtav 2e,z o <br /> DEPARTMENT USE ONLY qq <br /> Application Accepted By Date Issued__Q� G Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 LICENS-Ed CONTRACTOR MUST SIGNCENSE&WORKERS'd COMP ENSATION,DECLARATION <br /> UNIT IV- 6/23/99/sion 6knn/MT ,_-..._.__,, .._ <br />