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WELMPERMIT APPLICATION IORM 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 /> tu1� ,,4ssessors <br /> WELL Location ID �vTN wt $o Wu Cross Street-,Mirk City Zip '?Q Parcel# <br /> �nI f 1 /�-1 !b <br /> PROPERTY Owner fA - r\J j CM Address )yA E. Err-f,'I S+City �Od- Zips 5�hone# � (,- is-1 <br /> C-57 Contractor —Address 5X DLLCI t6' itrn�d� ��Al City kAf4V LII 1p%7Yltic#52LW Phonet,G/6)6'?y.vbf 2 <br /> Consultant/Sub Contractor"yice r� 01?0&I}owdAAtldress C225..frt 1-o City Lic#_6Q;-?Phone �-� 4/6 - <br /> GIS Coordinates:X , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 7(NEW WELL/BORING(CPT,lGEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> IS'OIL BORING# C PTI C PT a- p OVER-BORE <br /> 'Other: 0 WELL# 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n/ <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0' MULTIPLE CASINGS?0 YES W40 WELL CASING DIA: V <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL fn+ir'2 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes Oo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH R4V 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: C9T- 1SEOTHER __ CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> CwT 606.6c w111 Le aw&nntedIn -Ton Ril <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROA HMENT 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 /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICANT MU T CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Date � <br /> Signed Jl/1d < Title � /J1,2; ! '1 - (x/ <br /> Brian MIII�A'n <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> � � pp�� \\�/� �� DEPARTMENT USE ONLY r / <br /> Application Accepted By�rl�w�"'�+ Ir w" Date Issued Area <br /> Grout Inspection By n 1 s l.l)e natet-( (0 Q 0 Final Inspection By Date <br /> Destruction Inspection By --t. Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST It INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/Mr <br />