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vuFi p`�RItflIT APPLICATION FOR�.,­, UNIT IV <br /> Post-it®Fax Note 7671 Date #of <br /> I i 9 Pages IBLIC HEALTH SERVICES RECEIVED <br /> To a From �( <br /> Co. J TH DIVISION (PHS-EHD) <br /> Co./Dept. <br /> C�rd (zaxo a�H�l�f-e-0P vi`Iq( r, Stockton, CA., 95202 NOV 16 1999 <br /> Phone# Phone# 8-3449 <br /> Fax# Fax# is d-_-_------- <br /> �,RES 1 YEAR FROM DATE ISSUED <br /> App\ __, d/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 /> Assessor's <br /> WELL Location �(/ilShct/ (`: t Cross Street l�City S 40tkApr.3 Zip '7 &S Parcel#//111-(ate' �3 q <br /> PROPERTY Owner t C� �o Address �v Fs�33 Cityy' D[r�[ Zip G� 2f- r�Phone#°� <br /> C-57 Contractor Address 2365 W%$,..XM» Ar City _Zip Lic#,J(2.a6kPhone# 4,(oS 8712 <br /> Consultant/ b Contractor 1—f—r*r Ui Zero Address 1714(AMAI �J�. Cityg SG /aAf Lic# -- Phone# .92,MiW <br /> GIS Coordinates:X , Y ,Township Range ��#�;^ Section <br /> WORK TO BE PERFORMED <br /> KNEW WEL BORING PT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 DESTRUCTION(choose type below) <br /> OIL BORING# 56 0 OVER-BORE <br /> WELL# /'/� 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ff4OLLOW STEM DIA. OF BOREHOLE k „ MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL4 'BIR-150 TREMIE TYPE TO BE USED: ffAUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ees D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING 0 HAND AUGER APPROX. BORING DEPTH/R_ SDS 30—SAS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <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 performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'CO NSAT/ON La wslof California." <br /> E I PLICANT ST Ll. WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTp ONS. <br /> Signed x . Title �'�3 Date l <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: foil <br /> DEPARTMENT USE ONLY <br /> Application Accepted By A Date Issued ( �� � Area V V L <br /> Grout Inspection By E a Final Inspection By Date <br /> Destruction Inspection By Date <br /> CO MENTS/CONDITIONS:24 . <br /> CM <br /> Z—z <br /> ACCOUNTING ONLY: AID# FACA 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 1orlA IV/ 00 f <br /> C-57 LICENSED CONTRACTOR MUST SIGN LI E O RS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />