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' � "UNIT IV 1, <br /> W E <br /> LL ERMIT APPLICATION F :M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 " `; 7: <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : <br /> Application is hereby made l0 San Joaquin County for a permit to,construct and/or install the work described. This application is made 4r mp4i.a rpe:with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, EnvironmentalAssessor's eltt{ ivision. <br /> WELL Location t7 �vS Cross Street tbVn .e..'rcity !0.G Zip 53 Parcel's '- <br /> PROPERTY Owner iG Q �l� Address (Cid l-k amity Zip Phone# /� O� -�d3S-70�( <br /> C-57 Contractor n Address •� t ?� ��o City'Y 14 Zi 4 Lic#��Phone#Y��o– 72 7" W <br /> t7 ae s �►'+�- <br /> CcStrne#city�tr�- Lio- (p Phone# �33a-r.s <br /> Consultant[Sub ContractorW - SRU:ro axt ddress -L E <br /> Townshi_ Range Section <br />,,,-,-,,,GIS Coordinates:X Y P ,. ._. - -- <br /> WORK TO BE PERFORMED <br /> a NEW WELL 1 BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER'") Q DESTRUCTION(choose type below) <br /> SOIL BORING# E�4 � + 0 OVER-BORE <br /> a WELL# Q PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE.CASINGS?o YES o NO WELL CASING DIA: <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0-PVC a OTHER: <br /> []VAPOR o MUD ROTARY DEPTH OF GROUT SEAL ao TR MIE TYPE:TO BE USED: 0 AUGERS QHOSE <br /> D AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes. a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> *SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 2,g`t,330' a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER:_G OTHER CONDUCTOR CASING PROPOSED? (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_COIMPENSATION Laws of California." _Contractor's h.iring 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 /> CAWL THE UNIT:N INS 'ECTOR S WORKING HRSiN ADVANCE FGR,A IL"O UIRED INSPECTION$: <br /> ...... _ ._....____ ...__ ._ ..� _ <br /> Signed x Title/Company tA� <br /> Print Name 00 oek i P, Date _ <br /> E...'.. 1T A, IN U1�NIT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �( zrd--, � Date Issued y (n r to Area, n 7, <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By �/l�b.� y "� Date 7/Z, 71,0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE-INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> sv ��- �� 3/s(- C0 64/ vv 3v <br /> T t+_ 1/18/2000 <br />