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Fltt....0EPARTMENT USE ONLY <br />Date Issued ( ( c Area SC) <br />Final Inspection By Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Da <br />Date <br />WELL. .)ERMIT APPLICATION FIRM <br /> <br /> <br />UNIT IV <br /> <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 />e Assessor'ss, <br />WELL Location 5 -r m i y dd . Cross Street C ARICity St06417h) zip 92Cle Parcel# r 9-190 -0/ <br />2ty <br />PROPERTY Owner Ye Sh IC 0/041S Address /5.4e6r, $i ,'y' B tici City 5/cceirn Zip eb-z,C6Phone# 4-62.-41Z 7 <br />etrw <br />C-57 Contractor PI 4-0 II Pe; (,.4. Address 536c 5. tilar Avg'. City jilt Zip Y5gZe Lic# 6 11(.I 1Phone#.3gur <br />Corrt, / Sub Contractortieclillearep/~1/44 Address 445 A), 14;i 51,4 J7 . City 57ecebt) Lic#6010 Phone# 4Y<Lc1:17 /04:-/ ft, <br />GIS Coordinates: X Y Township Range -5-Ls— Section 2.5 <br />WORK TO BE PERFORMED <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />a SOIL BORING # <br />yytivELL # <br />O DESTRUCTION (choose type below) <br />0 OVER-BORE <br />PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />Ve<ONITORING "if:ALLOW STEM <br />0 EXTRACTION U AIR HAMMER/DRIVEN <br />0 VAPOR U MUD ROTARY <br />0 AIR SPARGE fl PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />POTHER: 0 OTHER <br /> cAl CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g; MULTIPLE CASINGS? 0 YES V116 WELL CASING DIA: Z. <br />CASING THICKNESS.54Ahlitk 40 TYPE OF CASING: 0 STEEL V•KC 0 OTHER: <br />S\‘ DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: VAtrGERS OHOSE <br />GROUT SEAL PUMPED: U Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') — <br />V) APPROX. BORING DEPTH "2-0 VOT:TED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />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: "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: "/ 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 />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x 'iT h; .„, Title 61.4k4)/e9 i 5 r Date <br />SEE SI E MAP IN UNIT IV WORK PLAN DATED: 10 October /999 <br />COMMENTS I CONDITIONS: <br /> <br />?r.er-t/li j:r• t 0 3 (A-, e-C4 2JJ /1/4.1/ <br /> <br />ACCOUNTING ONLY: AID# <br />FAC# p <br />PE CODES FEE INFO AMOUNT REMITTED REC'D.BY CHECK # <br />OC, <br />DATE PERMIT/SERVICE REQUEST INVOICE <br />3 o1 2.0o I30a /;./,A7 /1 /zzg7 sR# 0Z1253 <br />C-57 LICENSED CONTRACTOR MUST SIGN LIC WO RS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI