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IT APPLICATION FOR <br /> M UNIT IV <br /> WELL PERM <br /> SAN JOAQUIN COUNTY PUBLIC.HEALTH SERVICES <br /> � . <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stocktori, CA., 95202 <br /> {209)'468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> e with <br /> Application is hereby mads to San Joaquin County for.a perndttheconstruct <br /> StandardsnoflSaQT sn Joaquin n Counthe work ty Public described. <br /> Services, Envication is ronmental Heade in alth cDivis on. <br /> San Joaquin County Development 7itle,Chapter 9-1115 3 S�!y 9 Assessor's <br /> WELL Location <br /> p ,Sp�T le) �S o.K �� Cross Sireet W . " o City Citya S�ou� Zip Parcel# <br /> PROPERTY Owner A <br /> rco roe cwtl� �o Address Po 60 C> Ke _e,_Zip_1;*hone#,%.7,5 Af—A8?l <br /> Address City 40. Sac' Zipl�Lic#SS l� hone# 714,373711 <br /> 3' <br /> C-57 Contractor W C e <br /> Consultant ISub Contractor STrR-Ir, 3OC. wlll- � P <br /> G15 Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED j <br /> ' EW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> } �I <br /> 0 WELL BORING# 0 OVER-BORE <br /> 0 WELL 0 PRESSURE GROUT <br /> # <br /> F "Other: <br /> /+Tui ! T ry <br /> i COMMENTS: <br /> i TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r� <br /> i <br /> I MONITORING _ 1[HOLLOW STEM DIA.OF BOREHOLE <br /> 10 `r-MULTIPLE CASINGS?p YES NO WELL CASING D1A:�_ I <br /> t 0 EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS_JAG . — <br /> LfDTYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> {I 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ]]HOSE <br /> 0 AIR SPARGE 0 PUSH'POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') i <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Q &BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:-0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): 7 <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, 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 perforrnancerof the work <br /> for which this perm't is issued,I'shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting sign re ertifi flowing: "i certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'C MP S !O ws of California." <br /> T EA ICANT MUST CALL 48 HRS IN ADVA CE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title ✓p v JV(4 A-1s <br /> i <br /> SEE SIT MAP IN UNIT IV WORK PLAN ;-DATED <br /> DEPARTMENT USE ONLY <br /> 1, Application Accepted By Im Date issued r Tom Area <br /> Grout Inspection By Date Finaf Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> rib — t3� Z, IS R# <br /> C-67LICENSED=CONTRACTMUST MUSGN LICENSE &WO.. RKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/49 /sign bkpg/MI <br />