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Application Accepted By '1'1 <br />Grout Inspection By (A-tAnivIAP-•._ Date <br />Destruction Inspection By Date <br />WELWERMIT APPLICATION FuRM <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 />Assessor's <br />WELL Location 10 7 V - 5c Li 00( 5 t- Cross Street E I vvl City 1--.0 C. Zip Parcel# <br />PROPERTY Owner Jpc-- Address City Zip Phone# <br />C-57 Contractor C (ad Del Ikv9 Address 3 (.32- 04,0 . c C rci city fl'Jwci(o Co 4DiZip '/4 2_Lic#1 7iG Phone#q -63(5 -11‘ <br />Consultant! Sub Contractor /Qua (-kci v.,•,,,;ow•of$dotidress -W V t,t/ 15ci Way City 4516dflon Lic# 6 `i5,--')-/1 Phone# O.( '/OtAC <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />id NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # Vkt; 4 t 5w 3 )0 ci <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />['MONITORING Es HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />g VAPOR 0 MUD ROTARY <br />'KAIR SPARGE 0 PUSH POINT <br />0 SOIL BORING Q HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />I <br />DIA. OF BOREHOLE et) MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: )- <br />CASING THICKNESS C(1..14 TYPE OF CASING: 0 STEEL E PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 6 It 53 TREMIE TYPE TO BE USED: E AUGERS gHOSE <br />GROUT SEAL PUMPED: U Yes , g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 0 <br />APPROX. BORING DEPTH 60 U BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1\/ ( if YES, list specifications here): <br /> <br />COMMENTS: <br /> <br />Jo <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> <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: "/ 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 211124,-;1% 14/14 I4d Title PP'o j 4c I G (091 5 I Date L' <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 3) J411 t?-0(,'0 <br />DEPARTMENT USE ONLY <br />Date Issued (7)- Area (7 <br />Final Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# , <br />— <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE VOICE - - T . • ' a' , • <br />sR# to 1 91-L <br />-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' CLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI