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)J <br />Wt�L PERMIT APPLICATIO*-ORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS -EI- <br />304 E. Weber, Third Floor, Stockton, CA., 9520-2.1 <br />(209) 468-3450 JUN 0 3 199E <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C , 4 X1 <br />HEAL <br />1= <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliMr ip Idl i l<grtipli a ith <br />San Joaquin County Development Tdle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Service $ onmental Health Division. <br />WELL Location 5 <br />�17 Street <br />1/ -,Assessor's ors�arcet# <br />PROPERTY Owners!i•-J C) _Address 5) p:E[ `—Q�hone# <br />C7 <br />C-57 ContractorA 6o AOCresss� QwJ <br />`'3tG(09YVPhone# 7 )5b(a <br />Consultant ub Contracto J Address ,� c��, / ttv t; 2 Phone /(0 <br />X22 <br />S' <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED <br />AMOUNT REMITTED =ASH I RECEIVED BY <br />NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER-) 0 DESTRUCTION (choose type below) <br />D SOIL BORING # <br />Q WELL # <br />Q OVER -BORE <br />Q PRESSURE GROUT <br />'Other: <br />-CMMENTS: <br />T!PE OF WELL <br />/`M' CNITORING <br />CONSTRUCTION TYPE <br />HOLLOW STEM <br />CONSTRUCTION SPECIFI ATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES JrNO WELL CASING DIA: Z M <br />] EXTRACTION <br />VAPOR <br />AIR HAMMER/DRIVEN <br />MUD ROTARY <br />CASING THICKNESS TYPE OF CASING: p STEEL 21PVC a OTHER: <br />DEPTH OF GROUT SEAL I D TREMIE TYPE TO BE USED: R'AUGERS QHOSE <br />] AIR SPARGE <br />Q PUSH POINT <br />GROUT SEAL PUMPED: )ryes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 301 OLTED TRAFFIC BOX or O STOVE PIPE <br />OTHER: <br />CONDUCTOR CASING PROPOSED? d ( if YES. list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />nereby certify that I have prepared this application ano that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Ruwes <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, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies :he 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 California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL RE IRED INSPECTIONS. _. <br />,/ 7 <br />Signed x •• idle Date <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED L---1 -2y <br />Application Accepted By, <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />�Date Issued h, ! j Area 5 f <br />Date 611 -6� Final Inspection By Date r� <br />Date <br />h S <br />�I ACCOUNTING ONLY: <br />AID# FACT r^ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED =ASH I RECEIVED BY <br />DATE , PERMIT/SERVICE REQUEST NUMBER INVOICE <br />I 70 <br />i <br />UNIT IV - 5/99 /MI <br />