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AL <br /> <br />UNIT IV <br /> <br />orFr-cr-E <br />UiLLJtry- <br />eLoArry Rut) <br />Date Issued <br />Date Final Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: ( <br />DEPARTMENT USE ONLY <br />Date <br />L'Le-4 <br />SAN JOAQUIN COUNT i; - • v <br />ENVIRONIN - AffPg) <br /> AiLiumw'. ,4 <br />Application Accepted By <br />Grout Inspection By <br />WELL PERMIT APPLICATION FORM <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 San <br />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 2- I 0 Ai t_50,() t1J/4 Cross Street0N2Ler_vp City 67-0C..KTO/L) Zip cic205- Parcel# fs ij fet9 C0 <br />/3721 /e— Le-3 ki CV I-1 City -I Zip Phone# PROPERTY Owner <br />C-57 Contractor L) 14-1 Address City Zip <br />Consultant/Sub Contractor T77LL.rIAA, Address /Z7?Z ROPOJ 4-4k. City <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />VIEW-WELL / BORING ( CPT, GEOPROBE, HYDROPig.CcH, HAND-AUGER, OTHER*) <br />G-BOIL BORING # <br />[1,WEEL # Ru3 41) <br />COMMENTS: <br />, Township Range <br />*Other: <br />Lic# Phone# <br />Lic# I VC-2_ Phone# 360 -'121'3( <br />Section <br />0 DESTRUCTION (choose type below) <br />O OVER-BORE <br />O PRESSURE GROUT <br />TYP OF WELL INSTALLATION TYPE <br />MONITORING g-froaow STEM <br />O EXTRACTION AIR HAMMER/DRIVEN <br />a VAPOR OMUD ROTARY <br />0 AIR SPARGE a PUSH POINT <br />0 SOIL BORING fl HAND AUGER <br />U OTHER: a OTHER <br />• <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 11 MULTIPLE CASINGS? a YES Le1C-WELL CASING DIA: Z <br />CASING THICKNESS ,/ 40 TYPE OF CASING: USTEEL t3-10<5 fl OTHER: <br />DEPTH OF GROUT SEAL001.- 75' TREMIE TYPE TO BE USED: G AUGERS AHITS-E <br />GROUT SEAL PUMPED: erg- p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') Cul` <br />APPROX. BORING DEPTH 5-e) Li/0 i g-BCZTED TRAFFIC BOX or 0 STOVE PIPE It. <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: "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: "I 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 Califomia." <br />Signed x <br />Print Name .L72-11 A_ <br />IV INSP TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Title/Company if2E-MaiVtgiN6' <br />RECEIVED n 4-, Date <br />SEP 1 1 2000 SITE FILE ADDRESSNVORK PLAN DATE: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER EST # INVOICE <br />35of _ Ma) I 401 (a <br />35)/ 57 exp. WC/waiver <br /> <br />C-57 Letter of Authorization to sign permi Encroachment do-c(T) <br /> <br />5/17/00 <br />