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s � <br />WEL,.. PERMIT APPLICATION F,.,.RM UNIT Iv <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 c <br />(209) 468-3450 <br />w� <br />NON-REFUNDABLE PERMIT EXPIRES 1 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 />/ C Assessors <br />NELL Location �3rIy SCa/"�'K �7�tt' Cross StreelsT. C /'r' City Zip 7�✓' �ZQ Parcel# <br />PROPERTY Owner p�ylr7y, f- �Si Address /JeQ �e- krFca City Zip 9g3Z&hone# $ 38 - 3`f3Z <br />57 Contractor �T C.� �l�•� Address 50g S 1City n } ��J9 QQp 'hone#�(fr- �7z <br />Consultant /Sub Contractor. Address.a�J19,X 5i/�_City �Cy>LtrtLtc# Phone# 52 .ig-A` v' <br />SIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING <br />( CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />(Z <br />0 SOIL BORING # <br />=^ <br />0 OVER -BORE <br />C Y. 0 PRESSURE GROUT <br />) <br />'Other: <br />,KWELL <br />OMMENTS <br />O's"� Gxr tea.- <br />TYPE OF WELL <br />CONSTRUCTION TYPE <br />HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Spy MULTIPLE CASINGS? 0 YES ..a -NO WELL CASING DIA: _ <br />\ <br />$MONITORING <br />0EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />TYPE OF CASING. STEEL 15VC OTHER: <br />CASING THICKNESS d%!� 0 r� 0 <br />f\, <br />�� <br />]VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL �/� TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 4Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 20- �rg;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />OTHER: <br />CONDUCTOR CASING PROPOSED) x if YES. list specifications here). <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENGRUA(;HMtN I rtKnnl I,)! <br />hereby certify that I nave prepared this application and that the work will be done in accoroance with San Joaquin County Ordinances, State Laws, and Rwes <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the tollowing: "I certify that in the performance of the work <br />for which this permit is issued. 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />Lontracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. i shall employ persons subject to <br />AlORKI:MAN'S COMPENSATION Laws Of California.' <br />AP -LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/ Title GD�+��` Date <br />Signed x <br />SEE SIz K - <br />TE MAP IN UNIT IV WORK PLAN. DATED to[ 310c> <br />DEPARTMENT USE ONLY <br />Date Issued I \ I I D Area <br />Application Accepted By —�- <br />3rout Inspection By 1 �� r` Date Z /'C Final Inspection By t,L'vy4'rt Date CG <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />FAC# <br />ACCOUNTING ONLY: I AID# <br />II PE CODES I FEE INFO AMOUNT REMITTED CHECK#/CASH I RECEIVED BY DATE I PERMIT/�SERwV�EMBER INVOICE <br />e + <br />UNIT IV - 5/99 /MI <br />