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~ WELtPERMIT APPLICATION Ft+M UNIT IV <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-121-11)")304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> S 2 <br /> (209) 468-3450 <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 /> J Assessors <br /> WELL Location 23 •� Cross Street h City Zip-3GG parcel# <br /> P#tOPERTY Owner ka tAl!^1Address 4 pity A _Phone#12&SSr23 <br /> C-57 Contractor >�f•lE�« Address E City a., Zip2$W.Li�2Q Phone#f4a 979_"6 <br /> Consultant I Sub Contractor Address lSr7 City LidFpa Phone# 5Z2-E 4': <br /> GIS Coordinates:X ' y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL/BORING(CPT, GEOPROSE, HYDROP NCH,HAN[L�gUGER,OTHER") lI DESTRUCTION(choose type below) <br /> SOIL BORING* �oc�_�r,+s,c a OVER-BORE <br /> p WELL# p PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_Lr.�MULTIPLE CASINGS?l;YES Q NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A1,4– TYPE OF CASING: Q STEEL Q PVC G OTHER: <br /> a VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS QHOSE <br /> a AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALLi DEPTH IS 30') <br /> ,4SOIL BORING a HAND AUGER APPROX. BORING DEPTH o BOLTED TRAFFIC BOX or,0 STOVE PIPE <br /> a OTHER: _ r CONDUCTOR CASING PROPOSED? (if YES,list specifications dere): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR EWROACHMENT PERMITSI <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 Rales <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 1 certffy that In the performance of the work <br /> for which this permit Is issued,1 shall not employ persons subject to WORKMAN'S COMPENSA77ON Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomia." <br /> THE APPLICANT MUST CALL 48 HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signedx Title k Date <br /> SEE SITE MA IN UNIT IV WORK PLAN. DATED -f4f ,� -r7 - a <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued l O Are <br /> Grout Inspection By Date Final Inspection By If I Cft9 to <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECENED BY DATE PERM SE ICE REQU T NUMBER INVOICE. <br /> 3s"b I �00 SII Ir rY 3 l `t ! 3 <br /> UNIT IV- 6/18/99/sign bkpg/MI <br />