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<br />lEcin v ELL PERMIT APPLICATION FURM UNIT IV <br />SW /JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAY 1 6 2000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENViRONMEN1AL HER* E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (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 />Assessors <br />Cross Street Oak- city 3i-cx-O-Ori Zip Parcel# <br />PROPERTY Owner (_V1 Sivi tAJos Address )OS-6 lion City 5 404qt ri Zip 0- Phone# <br />C-57 Contractor 1ti lk-6efi •E-ov, Address 5360 A-ve City 5aciu,)7) Zip9 c,‘Xj_ic# 6-7,26/ 7phone#(9/G) <br />CitY +0(4-0,-) Lic# (42)7 Phone# 'i'6 7 066 <br />GIS Coordinates: X <br /> <br />, Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED <br />f(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />OIL BORING # <br />1KWELL # iw&ii - LA) Li <br />1:1 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE <br />xt-OLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6 " MULTIPLE CASINGS? 9 YES „411-0 WELL CASING DIA:d <br />CASING THICKNESS /VAL TYPE OF CASING: ['STEEL .trIDVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: )j\-AUGERS DHOSE <br />GROUT SEAL PUMPED: _R-Yes 9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH S' 0 60 OOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /144 ( if YES, list specifications here): <br /> <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: "I 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company 6e0(0 <br />Date <br />Grout Inspection By 1'\'}AAAA <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE 15BA44-T-t-S-ERVtCt—RE9-LX INVOICE <br />CO ( SI Sn . 00 I 3 b% AL 51"-/SR# 00 a.a4g5 <br />WELL Location (,°,71- A ). Cciirforni-t) <br />0 <br />Consultant / Sub Contractor Address -{ /11 <br />Signed x <br />Print Name r co-, /141 I lin uvl <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED`:: <br />DEPARTMENT USE ONLY <br />Application Accepted By (11/4,1./VN.CA01 Date Issued .-1/ Area <br />Date 4.; )ro Final Inspection By Date c3- 7-if(C7c / <br />Date <br /> 17 8/2000