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///3/,9 <br />Area 6) \pplication Accepted By <br />;rout Inspection By <br />cr-3 <br />Date Final Inspection By Date <br />Date )estruction Inspection By <br />:OMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued /0 —V <br />WELL. PERMIT APPLICATION JRM 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 />WELL Location)/(0 iVy Cross Street t/'/,‘-e.Z--2,--1,1City <'62-7/C3c.ip Zip Parcel#'' <br />Asses's <br />PROPERTY Owner Mt3.0 — Address 521 Al SY' City S-2&.14alp L Zip i Phone# &L.-6 <br />C-57 ContractorndLAY5d e27e:i---b Address Pr2c- )14X-r-72( W.4('Cityhjp 95-70jc#4,:r/22-?hone# )7 kia"z <br />Consultant / Sub Contractor AO- <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />Address City Lic# Phone# <br /> , Township Range Section <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />O SOIL BORING # <br />*Other: <br /> O WELL # <br />COMMENTS: <br />O DESTRUCTION (choose type below) <br />fl OVER-BORE <br />0 PRESSURE GROUT <br />INSTALLATION TYPE <br />O HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />,...13-FrUSH POINT <br />O HAND AUGER <br /> 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 " MULTIPLE CASINGS? OYES 0 NO WELL CASING DIA: <br />CASING THICKNESS r TYPE OF CASING: 0 STEEL 0 PVC 9 OTHER: <br />DEPTH OF GROUT SEAL 6-7/2"-)(--Y TREMIE TYPE TO BE USED: o AUGERS OHOSE."---„Q <br />GROUT SEAL PUMPED: 0 Yes 9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 304--, <br />APPROX. BORING DEPTH -?c=73 0 BOLTED TRAFFIC BOX or fl STOVE PIPE <br />( if YES, list specifications here): <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />IL BORING <br />j OTHER: CONDUCTOR CASING PROPOSED? <br />.4./6e4-e.Z.1 Ltagetd 14/err-A "S-r• <br />NOTE: OFFSITE ORING REQUIRE ACCESS OR ENCROACHMt4° P RMITS <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 />3 n d 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 />or which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub-:ontracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />'YORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />iigned x a)662CeKe7(/)4/6dei Title Date 2 crF9 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: (0 --/5---. <br />Zate;,..r S d :OMMENTS: <br />ACCOUNTING ONLY: AID# <br />, FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />09e,‘a c_<2 /04il 9 S R# DO (2 /006, -SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />NIT IV- 6/2 3 /9 9 /sign bkpg/MI