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UNIT IV WORK PLAN DATED SEE SITE MAP IN <br />/ it <br />Application Accepted By <br />Grout Inspection By 2 <br />Destruction Inspection By-, \ <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued 1(/6V Area <br />Final Inspection By tA)i-ti\AC Date Cs" <br />AIDS ACCOUNTING ONLY: INVOICE PERMIT/SERVICE REQUSLUMBER <br />1FAC# <br />DATE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKft/CASH RECEIVED BY <br />0C) <br />Date `< <br />Date <br />L•i• ; .4-PC•Jr- <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) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />UNIT IV <br /> <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. Assessors <br />WELL LocttliorQ° i'- i...0,-C:.\-C .;. e• kMe....; Cross Street ?0 iktr Alt CityCkt CVS1 \ Zip Parcel#M1- 464 -14 <br />PROPERTY Owner `NAA-9 YAM •C4,1-1.4/, ,Address C A '{,Pox..te(diz.,-/-( Cy 5-ft.:24 1-1Y--,zic: 9 ").2:;.-7- proorleqtt 'h) / 6 6 <br />C-57 Contractor(YrttlsoN V't":% \ \°‘ Yv5 Address°60 WO4ic Ck,. city mo,A,v,c2 ziptiLks 5 3 Lic#41s 165 Phone1(ciLS)3 t a -s sr(ro <br />Phoned (101)c(3-41s0 <br />WORK TO BE PERFORMED • <br />g/NEW WELL I BORING ( CPT, GEOPRO6E. HYDROPUNCH. HAND-AUGER, OTHER') <br />U SOIL BORING <br />trWaL (A1/41.)-1 K\LI - <br />'Other: <br />rf PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS , 0 COMMENTS: <br />(MONITORING irHOLLOW STEM D. OF BOREHOLE, ii It MULTIPLE CASINGS? a YES tt<I0 WELL CASING DIA: 2 ti S--- <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSCOlv 40 TYPE OF CASING: 0 STEEL tK:NC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL" 6 ô t TREMIE TYPE TO BE USED: VAUGERS aHOSE <br />Q AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: s.ifes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ---' <br />Q SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH "-** %0 t Erg OLTED TRAFFIC BOX or a STOVE PIPE <br />3 OTHER: <br />CONDUCTOR CASING PROPOSED? N.1 0 ( if YES, list specifications here): <br />C <br />COMMENTS: <br /> > <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: <br />"I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hinng or sub- <br />contracting signature certifies the following: 'I certify <br />that in the performance of the work for which this permit is issued. 1 shell employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />THE AP1JCANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />MI AZ( . 2/a6/0/ <br />Signed x <br />rC,114s,r-‘0,4i,r51010;\11,.\ Addressa.-7 0 briKtv•S VV. city SDhort%o. Licts <br />Consultant Sub Contracto <br />Range Section <br />GIS Coordinates: X , Y Township <br />O DESTRUCTION (choose type below) <br />(3 OVER-BORE <br />a PRESSURE GROUT <br />0