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ORIGINAL <br />t .fit <br />APPLICATION FORM SNIT FV <br />AID# <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />FEE INFO <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />CHECK # <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />DATE <br />PERMIT / SERVICE 5# INVOICE <br />(209) 468-3449 <br />. <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 />�3SR#DOvb6 <br />San Jo acui Countype opment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location A.50 C7c;,� i 9 I tui t3Lyi) Cross Street ?.Lrri City STUr-A TCJR1A Zip '15 7.�Parcel# C) w <br />_Address =t!2 JAQgJNELNQ.A0 City;vacKTolV Zip 5Zq.'- Phone#(1066)'137-•g3gq <br />PROPERTYOwner_C_ZTY _:'�Ti1cYT 4 <br />�J <br />(LAN �HGi <br />C-57 Contractor CA`1C/AIDE ptiTLL�htC� Address 3632. Qm -C C P� L� City coanatA Zip, �•`t Lic# ft75rO Phone#jgt1,)t,i?5-t I( C1 <br />Consultant/ Sub Contractor; nevirvvrvt><NrrAt.-.,xrvC_Address 3`51 SNEw vL. CityLic# Phone#Cz�a`r)We»-f-Ic<C. <br />GIS Coordinates: X , Y Township Range Section <br />O <br />WORK TO BE PERFORMED <br />Q NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING #_ 0 OVER, -BORE <br />MWELL # t-4 W ' 1 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: /\T %ACJi 11 —rL-> wofl-y PL INN DA- eC, 15 TANQf--AY? Y ZvU-f <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE `3" MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: 7." <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5Lh,r �I y TYPE OF CASING: 0 STEEL . PVC BOTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:`,�UGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER, APPROX. BORING DEPTH r-k�' ,e H BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? 06 (if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared ;his 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: "1 certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting 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 />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed Title/Company 'rAht SCIet�tt"z "T/Avg �at�ic t� i FU'cs�tVZ�2csd 1plTAt_ <br />Print Name <br />SEE SITE <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection E <br />COMMENTS I CONDITIONS: <br />Date 112-3 /o 7 <br />P IN LIMIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />_ _-- <br />Date Issued <br />Date Coo 3/ D inal Inspection By , to <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE 5# INVOICE <br />. <br />Z52}L <br />�3SR#DOvb6 <br />