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WELwPERMIT APPLICATION SRM 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 /> i Assessor's <br /> WELL Location l 7 V- 5c � Oct� 5 �•- Cross Street WI City L�D Zip Parcel# <br /> PROPERTY Owner _�ac Address City Zip Phone# <br /> C-57 ContractorLalcad-f Dr;11;Uq Address 3632. Ompc Ctrc(g City&kc4b (0 ZipQy,14ZLic#111 SI0Phone#g16-63$-ll6q <br /> Consultant/Sub ContractorAJvaLi(-cJ &, & Eg N;v..iw,dAbdressuooy IV-wilso•g way City`7lbclflen Lic# `60;4 Phone# L167'1CL')1C <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL#Vul1,, -1 t SLv' j )v cl 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I&HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES RkNO WELL CASING DIA: Z r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc 1..N D TYPE OF CASING: 0 STEEL Q PVC 0 OTHER: <br /> 1W VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 1,53 TREMIE TYPE TO BE USED: JI AUGERS IIHOSE <br /> J(AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 60" 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED k/ (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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <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 California." <br /> qq THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x / �nl,t,( % Title Pi'oj+c J G�eIo91'SI Date -� g'O0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 31 Jgo ..1,000 <br /> __ DEPARTMENT USE ONLY <br /> Application Accepted By / l , Date Issued o1— Area <br /> Grout Inspection By Date — d9 Final Inspection By Date <br /> Destruction Inspection By Date <br /> 11 V <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35 0 1 s5 13 q a--5- by y I t <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />