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I 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: "/ 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." Contractor's hiring or sub- <br />contracting signature certifies the following: l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws o alifomia." <br />THE APPLICA MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />(),1 '&1 GC/2 Title Date Signed x '7 -ID (c) <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED I v L-f 6, 1999 <br />DEPARTMENT USE ONLY <br />Application Accepted By /14/49,4A-#-'“ Date Issued 7/131 <br />Grout Inspection By <br />Destruction Inspection By 7-1 q9 <br />Date Final Inspection By <br /> <br />Area • 0 te <br /> <br />Date <br /> <br />WELL PERMIT APPLICATION FORM 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 />GO 9 '-'3C,4n <br />1: 03 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 />Assessors <br />WELL Location III 5. A S To C Ki014 Zip 95203 Parcel# SN TO A Q QIN >1". <br /> <br /> City Cross Street HA -LEI-To/4 <br />PROPERTY Owner MARIAN F RNi Address P.O. B OX 510 City 11A't w A KD Zip 5its43,phone# (s-i 0)2436- s000 <br />o <br />C-57 Contractor V DRILLING- Address 13. 0. B 0 )( 51 city <br /> Ri <br />isrA zip 91s-t1 Lic#110904 Phone# (01) 3i it- 1815 <br />NANcliv R, <br />Consultant / Sub Contractor R AM AG Eriv . Address P. 0 • iloX 8 6 9 citymv ig TA LiC# 5 13 5 6 Phone# 010354-32SO <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />B WELL # <br />I DESTRUCTION (choose type below) <br />0 OVER-BORE <br />I PRESSURE GROUT <br />*Other: <br />COMMENTS: PFSTR0I 3 cN - S I T E w a i- L S 13Y PResswg E G-Rovr <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: --i) <br />1] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS OISHO3S0E <br />0 AIR SPARGE <br />1 <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />COMMENTS / CONDITIONS: "CI) 6 Z.,) /04.441_24.A.4_, <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHEC61&SH RECEIVED BY DATE PERMIT/SERVICE REQUES UMBER _ INVOICE <br />UNIT IV - 6/1/99 /sign bkpg/MI