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WELL PERMIT APPLICATION FAM 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) 468-3449 <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 />NELL Location 133 IV- Ad AIT F1,71,l. _Cross Street 0il'= (�-1t k6ty S TcC h /n Zip ` ti % 1 Parcel# is <br />?ROPERTY Owner ��� r 5, N (6:- 0 Address 7° v� City Zip Phone# y 1' 7 7 7 <br />C-57 Contractor A� V� ((f (,-c P w i r''Addre s( 'iOO 5 V W;( -;O" L41v Y City 5 Zipd 5)-D F Lic# 6 `60,A;7Phone# L4 11j J <br />Consultant / Sub Contractor j2--- Address City Lic# Phone# Y <br />3IS Coordinates: X Y Township Range Section IJ <br />NORK TO BE PERFORMED <br />] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUN H, HAND -AUGER, OTHER-) <br />(,SOIL BORING # I <br />0 WELL # <br />'Other: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />-lam <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />] MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE : !' MULTIPLE CASINGS? 0 YES p NO WELL CASING DIA- <br />] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS V/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T• P TREMIE TYPE TO BE USED: 0 AUGERS ;@HOSE <br />] AIR SPARGE &PUSH POINT GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 30 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />] <br />OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? 00 ( if YES, list specifications here): <br />COMMENT <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />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, 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 wort; for which this permit is issued, I shall employ persons subject to <br />,NORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed xTitle/Company <br />h- (� .F . <br />Tint Name I` -k V I M M'K*. V 13 N Date <br />SEE SITE MAP IN UNIT V WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />4pplication Accepted By (1-11 Date Issued —1 a— 00 Area 0 73 <br />3rout Inspection By Date Final Inspection By Date <br />Destruction Inspection By (y<� / Date <br />COMMENTS I COND <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />1/18/2000 <br />