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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 />RECEIVEL <br />NOV 16 1999 <br />*ls'd <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 />Assessor's <br />WELL Location S PrAyl-Bw/I Urc)O4 Pr:. Cross Street 0 VO--C>AN:kr City MCV4-(61 Zip 5533 Parcel# <br />PROPERTY Owner ksal4u,. tikrrt Address SI SI Alv-6"cluxod .1): City PfrAgNi.eCCk Zip 9•5337Phone# <br />C-57 Contractor 1SciA. SAVIYDA. Address 311 DA/06 's PI4ke_ cityvAkm 5prt ?2kic#1&6 phone# 7 -b. 3slo <br />Consultant / Sub Contractor CIY1DtArli 2-trp Address 171* 14.04,,, City aC046V1 Lic# Phone# g.n 9 <br />GIS Coordinates: X , Y , Township P---S Range 76— Section iciF" <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />vg'SOIL BORING # %R3 <br />`G WELL # <br />O DESTRUCTION (choose type below) <br />0 OVER-BORE <br />fl PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 1 MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />DEPTH OF GROUT SEAL 2S— TREMIE TYPE TO BE USED: LAULGDEER:TH Gis1-103S0E), -(...0, <br />CASING THICKNESS WA TYPE OF CASING: 0 STEEL 0 PVC I] OTHER: <br />GROUT SEAL PUMPED: 0 Yes G No (NOTE: MAXIMUM FREE-FAD <br />APPROX. BORING DEPTH 25 — 0 BOLTED TRAFFIC BOX or I] STOVE PIPE ...,:s <br />CONDUCTOR CASING PROPOSED? WA ( 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 Rul <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the war <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- 0 <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 <br /> <br /> Title Cis* ek? (c)—/C- Date 12-) <br /> <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: p_iql7 <br />TYPE OF WELL INSTALLATION TYPE <br />fl MONITORING 0 HOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />a AIR SPARGE XPUSH POINT <br />FOIL BORING j HAND AUGER <br />0 OTHER: 0 OTHER <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By (A 011 <br />Destruction Inspection By <br />I 212- g? Date Issued <br />Date 1 z.,(19-11') Final Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE: ,,------r------ • ST # INVOICE <br />WO I .1 ..o 0 009 s- I T- (A-( 141?-11 ; sR# 00A I coCY <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />" - • _ Ill • <br /> <br />ON <br /> <br />- • <br />