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-05-2000 3:0.3AIA F'ROW P <br /> t� <br /> WELL 'PERMIT APPLICATION FORM: 'UNIT IV <br /> SAN JOAC ON COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION'.(PHS-EHD) <br /> 304 E. Weber, Third Floor; Stockton, CA., 95202.1..% <br /> (209) 468-3449 <br /> 4 <br /> NON-REFUNDABLE PERMIT EXPA6 9 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for',a permit to construct and/6r install the work described. This application is rri a 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 I OCation �. Cross Street��_ClEy Zip_Parcel# <br /> PROPERTY Owner YIP G?!7 k e I-7Ceg_t _AddressP4 QQt frW3T -- —City Mcde&ilA Zip " <br /> C-57 Contractor f} l[DS ntl -.`Address Ji ','f- V`t(/- 064 O V Zip _Lic#_ Q0 hone#`-/d J <br /> i <br /> Consultant/Sub Contra tc or S /1_tL,�Address f 5:j7/0."'C_J� /P�r c:City�i%#�v `.L.-Phanei! s X 81 °1 a`�5 1F <br /> RG <br /> GIS Coordinates:X Y Township _,Range Section <br /> F: <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL i BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,.OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# PRESSURE GROUT <br /> COMMENTS: if!! <br /> TYPE OF WELL INSTALLATION TYPE CON$7RUCTEON SPECIFICATIONS �,A <br /> %/I MULTIPLE CASINGS? YES NO WELL.CASING DIA. <br /> � �MONITORINCs Q HOLLOW STEM DIA.OF BOREHOLE �I_.. g Q <br /> h: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN.. CASING THICKNESS&__TYPE.OF CASING: n STEEL 0 PVC 0 OTHER: AM <br /> k 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL IVA TREMIE TYPE TO BE USED: 0 AUGERS QHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. 'Yes ,0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D 501L BORING d HAND AUGER APPROX. BORING DEPTH, ,oma �D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />`r p OTHER p OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> 0. <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHME=NT 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 Regutations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: `7 certify that In the parformance_ofthe work <br /> for which`this permit!s issued;'l shall not employ parsons su6jecf to WORKi25'COMPENSATIOlY Laws of Ca!lfornla:"rCantractor s'hiring or`Sub- <br /> contracting signature certifies the following: "/certify that in the performance of the work for which this permit is issued, !shall employ persons subject to <br /> f WORKERS COMP NSA71ON Laws of California II <br /> i 7H A0 ''ANy'1V'U `i +A yl $WQ E 1N HRS IN DVANCE Q t`i LL RE I�IRED:li�9 Fy CTIQNS <br /> Signed x /l1Lt✓II , Title ._,__ -- Date Z`16'`00 <br /> SEE SITE MAP IN UNIT IV WORK 'PLAN DATED: <br /> f 'DEPARTMENT USE ONLY <br /> Application Accepted 5y �� !` �U - --- - - - Date Essued, 3 L. '� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By bate. <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE COPF,-$ FEE INFO AMOUNT REMITTED' CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 5soz~ 60. 00 191Z &Z 3 SR# ppzZ07- <br /> C;57:7C7K1S 'CI 'x' T0V [] i " XOV CFNE..S ' bR z ';CN[iENSA T'�CN3EGTT4iV <br /> UNIT IV-6/23/99/sign bkpg/MZ <br />