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WEL PERMIT APPLICATION )RM UNIT IV�p <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA , 95202 r 2? ;;y fit: 42 <br /> (209) 468-3449 !tel <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> Application is hereby made to San Joaquin County for a permit to Construct and/or install the work described This applicatio aoihance <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> WELL Location '050 WOAtr(" EA Cross Street St e,rrk L K. Ci zip Assessor's <br /> secs is <br /> /f city 5-hoc -Go'�_._ p <br /> PROPERTY Own�errQV�I�ffr"AA t 14C` Address r' Cifty� T d el+Zip131. Phone - t�5 <br /> C 57 Contractor_Y G W 4?Y'r 1 Address t4ii L City ��L. Zip CZ�O�Phone# t p <br /> {!s Po�v r <br /> onsultant Srtb6errlrecrer ( Y[ f(�T�rJI, !Address f City�L=c# Phone#���Z C <br /> GIS Coordinates X Y Township 7i r Range (9 S Section 3 <br /> WORK TO BE PERFORMED <br /> 'NEW WELL t BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) a DESTRUCTION (choose type below) <br /> (�- 0 SOIL BORE G# 0 OVER-BORE <br /> ELL# - I 0 PRESSURE GROUT <br /> 'Other ii.'� <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Sr <br /> ,'MONITORING HOLLOW STEM DIA OF BOREHOLEMULTIPLE CASINGS-)0 YES )(NO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DMVEN CASING THICKNESS !_G 0 TYPE OF CASING 0 STEEL )(PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALSeR COW- ""REMIE TYPE TO BE USED 0 AUGERS ROSE <br /> AIR SPARGE,k2 0 PUSH POINT GROUT SEAL PUMPED XYes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> WSOIL BORING 0 HAND AUGER APPROX BORING DEPTH-Sgd0M!! S -X111OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER 0 OTHER CONDUCTOR CASING PROPOSED? NO (if YES list specifications here) <br /> COMMENTS 1A J 'Z' r - r KYJ <br /> -fL. o� 5 eAl s AS -1 ' 155 KW-1( '. ZS <br /> N TE O FSITE 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" Contractors hiring or sub- <br /> contracting signature certifies the following 'I certify thatin the performance of the work for which thrs permit is issued I shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cahfornra" <br /> PPLICANT MUST CALL 488 ,WORKING H1RS//J�IN ADVANCE F�OQQR ALL. REQUIRED INS E�jCTIONS <br /> Signed x �Y o' �v7r mjLc icTrtle_�i S Je-yA ^-69 e,LrSI-Date 9 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> <;�I� � DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued QB'Z4•ZA0C] Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> I N�uJ 59(0f B-2-Z S Rf <br /> C-57 LXENSV�k,CONTRACZ'OR`N T SIQN LICENSE&W4 RS: 3fPEN5ATION DECLARAVON <br /> UNIT IV- 6/23/99/sign bkpg/Ml <br /> ✓' ZC57- <br />