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WEL.— PERMIT APPLICATION V iRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <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 />3C M0FFA T V7. 511E RM AN Cit ,1AN�VC Zi <br />Assessor's r'sa�l-�y0-3�{-8 <br />WELL Location '''� � L Cross Street y A p) 5 i i �: Parcel# <br />;:RANr, 4 <br />PROPERTY Owner 1` 0 5 iE 4LZAViAddress. `t3 C, M 0 F F A -T O L V P City MA NTE( A Zip `JS 3 36 Phone# -40') - `623 - 11 <br />*4A -LE'y <br />C-57 Contractor FIS (i+ F NV Address 3) % S 11 E 1I 1'S p t -A 4 t CityS r li JN \.-S Zip' 5 25 1. Lic#1-t3? E S Phone# 2(;9-7 12- 3 5lc <br />RANCbC (�-k' <br />Consultant / Sub Contractor IZ A M A C- c E N 'V Address I' C. U C A �' c t� City Mui: t E f A Lic# 401 i (o Phone# ) It - 33't - 31 �; o <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />1 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />Vv <br />SOIL BORING # (35; G J 0 OVER -BORE v <br />0 WELL # 0 PRESSURE GROUT <br />'Other <br />COMMENTS: 3 C -GCI eCt;V 13cRtwCS CFF Gr AURIC* .LJVRAL IGNER'S J i rE <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS d <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 7- - I N MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: NA T1 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z9 - F E E T TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE I PUSH POINT GROUT SEAL PUMPED: 0 Yes 1 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH i-5 " Fy r- F 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />OTHER: C LC P K G d V-- CONDUCTOR CASING PROPOSED? 1"C ( if YES, list specifications here): <br />COMMENTS: Sk:i.PE GF WGaK 0kiAILE1) ir1 r\AMAC-C FNVit?,uwi"1rW-1AL'S VVrRk-, P00J ^�^ <br />l' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />1 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 WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: `/ certify that in the performance of the work for which this pennit is issued, I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />- THE APP C SCALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/L. %- 1 <br />Signed x Title lam' vv V�' Date C <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED T v,-jc li ; I Jy+ <br />DEPARTMENT USE ONLY <br />Application Accepted By l c(% <r — Date Issued i , I Area <br />Grout Inspection By Date FJf Final Inspection By Date / T <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE <br />PERMIT/S EQUEST NUMBER <br />INVOICE <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />