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Et Cv I F; <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 2 � WEIT IV <br /> ENVIRONMENTAL HEALTH DIVISION nA n ^� <br /> 304 E.Weber,Third Floor,STOCKTON,CA 95202 _ �YIH <br /> (209)468-3450 "1�^s V1cN AL HEALTH <br /> FU1��( 1�.C��1lICE$LT�' Z <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE{9-P A*}.1�,;,-' <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 /> � Assessors <br /> WELL Location� t �"w;L 4 L3� U i] Cross Street C i-�=�=uL- ?`-' City ��'�� Parcel# Zly- I8i % I <br /> PROPERTY Owner's Name (ALr_STc2 J Address <br /> Contractor C��r5 �sScXc 'ic'S Address'X*%4o i-Lic#___Z 2T"t,1 I Phone# Oz<)s LS'`f t//E <br /> S-Zo <br /> Sub Contractor Jl t�c`.•�r Y�'^'s Address Z3,7 Z Fca�t s'T Lic# 7C5'`i21 Phone# Si Z(p<G�r✓`r(o-j <br /> WORK TO BE PERFORMED <br /> 'NEW WELL/B-ORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> gSOIL BORING# 541-1 f 63 --Z- 0 OVER-BORE <br /> 0 WELL# _ 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE i tJ MULTIPLE CASINGS?0 YES &_NO WELL CASING DIA: <br /> -&- <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS PJ IA- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: W& <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]`'SOIL BORING HAND AUGER APPROX. BORING DEPTH (C Fr7 3c>5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 7 OTHER: CONDUCTOR CASING PROPOSED? Ait (if YES,list specifications here): <br /> COMMENTS: 5G -I 14-o.A S R. -Z. (,J LL- 3c I(V oT-Ac-u.G --+k.; I*`S T nC.A4L <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> iereby 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 /> 3r,d Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: 'I certify that in the performance of the work for <br /> .vtich this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub-contracting <br /> ;,gnature certifi the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to WORKMAN'S <br /> ,;OMPENS O Laws WCalimia." THE APPLICANT MUST CALL 48 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)468-3450. <br /> Signed x C,?AI kl A - Title Date /9DO <br /> I <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued ✓ ea <br /> Grout Inspection By d Date Final Inspection By e <br /> Destruction Inspection By Date <br /> COMMENTS: .5a-40i10 07 St.�/ �jG 77 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ZQo 5 ZS (v C' `c- SR# O 3 <br /> ,,NIT IV/10-98/MI <br />