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WEaERMIT APPLICATION RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) p <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 D <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 /> '40(p 5 .7Zic �]u / -F Assessor' <br /> WELL Location V' lLr . .Cross street C]� fcnJ[edgl City. U—'`�UIJ zip ZC� .Parcel# 7F?-/90 <br /> PROPERTY Owner YG ShID `6W%fy< A Address 5 4C(c S. f r 20y <br /> �ALI/alod it r 'last zip SZt Phone# ,J1 2-4927 <br /> C•57 Contractor p J] p,^;�I,1p7 LiJJ Address .S3(00 S, aAtr ode': cit Ito <br /> T y.SRG Zilpjy Z Lic#6r2G�IPhone#362-M 660 <br /> Con /Sub Contractor ,t 1,&:1VM4!1k1, rens W. l•Yi t+j . City 57z'c��,.t*) Lic#foQLL Phone# Lv9 <br /> /too <br /> GIS Coordinates:X ,Y ,Township Range SG Section 2 S <br /> WORK TO BE PERFORMED <br /> EW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> p SOIL BORING# p OVER-BORE <br /> 'Other: 'WELL# 7 O PRESSURE GROUT <br /> COMMENTS. - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE Com. MULTIPLE CASINGS?a YES V405 WELL CASING DIA: Z I/ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-5k40 dile TYPE OF CASING: 0 STEEL VOC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-'1.5'/ TREMIE TYPE TO BE USED: tVkCrGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No .(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH - D r TED TRAFFIC BOX or O STOVE PIPE <br /> O OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?_ry P (if YES, list specifications here): <br /> t <br /> COMMENTS: <br /> i <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, Stale 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'COMPENSA TION Laws of California." <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQU11 IRED INSPECTIONS: <br /> Signed x Title Date Cl ZZ g <br /> SEE SI E MAP IN UNIT IV WORK PLAN DATED: /D Dc-tobev' ./999 <br /> EPARTMENT USE ONLY <br /> Application Accepted By 1 . (/ Dale Issued_ `( / �! Area _/ <br /> Grout Inspection By , i at i Final Inspection By Date <br /> Destruction Inspection By G£" Date - <br /> COMMENTS I CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# - <br /> IPE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT/SERVICEREQUEST# INVOICE <br /> - I01 q ,00 30 y Ii Zz 021253 <br /> C-57 110ENSED CONTRACTOR MUST SIGN LIC WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> I <br />