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WELL PERMIT APPLICATION FORM UNIT IV <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 ,plic2tite, IS hereby made to San Joaquin County for a permit to construct and/Or install the work descnbed. This application is made in compliance with <br />,n Joaquin County Deve!opment Title, Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division <br />ELL Location 2s/2 N..5. ttew St. cross street 4:: /11rne."- CitY4c7L-47Ck#17r7 Zip '670 0 PAas /Ices! sts - z -42 .5— <br />tOPERTY Owner 5-7,4Yr, com-f-e, Address 204 1-47;ipa1 5j 114470 city5aii Fin:7 i.cijr..41p7479 phonc ir -6", 9, 2 <br />57 Con:raCtor a/In7 <br />L <br />/2 Z Kt at Address P' 111ek,ity C-g•-•dwvi Zip ?S7racc/ii S i19.7r,onotiV4)4538-7,z76 <br />maul tantI Sub ContractOrldro -6ets' CaluelheatlkdOress 1! a gcsix 4/ 3 s-3 Citytl 7 V ia.' oesce--6. y (9 ehoneOcs-ci)yz8 -42.yes <br />/10 311-- r acct;r1r. <br />S Coorctinales X <br />ORK TO BE PERFORMED <br />fNEW WELL / BORING ( CPT GEOPROBE. HYDROPUNCH. HAND-AUGER, OTHER') <br />SOIL BORING 0 <br />WELL. 4,4-77) <br />Oat: <br />a DESTRUCTION (choose type below) <br />11 OVER-BORE <br />a PRESSURE GROUT <br />INSTALLATION TYPE <br />AR <br />STEM <br />AIR HAMMEFVDRIVEN <br />0 MUD ROTARY <br />a PUSH POINT <br />a NANO AUGER <br /> C OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I MULTIPLE CASINGS/ a YES )(NO WELL CASING DIA "Z.-II <br />CASING THICKNESS 4iriirl •(-1 V TYPE OF rASING. a STEEL PVC 0 OTHER <br />DEPTH OF GROUT SEAL n.i I -I, ' TREMiE TYPE TO BE U ED a AUGERS amOSE <br />GROUT SEAL PUMPED: a Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX BORINC. DEPTH le 1:1 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 100 (it YES. list specifications here) <br />-1MMENTS <br />'PE OF WELL <br />)4MONITORING <br />EXTRACTION <br />VAPOR <br />AIR SPARGE <br />SOIL BORING <br />OTHE R <br />IMMENTS 3ehttni.040'0";Pfl 4/roll$ 240 ckt•74-4_ ct.lc V°I CZQ ' c <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />lereby 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 />id Regulations of the San Joaqurri County Homeowner Of liCensed agent's signature certifies the following. "f certify that In the performance of the WO ,* r which this permit is Issued, i shall not employ persons subject to WORKERS COMPENSA7708 Laws of California." Contractor's hiring or sub- <br />intracting signature certirtes the !clawing: 't certify that in the performance of the work for which this permit is issued, i shall employ persons subject to <br />'OPK_ERS' COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />n (7 —7--- --... i (-) t) ii /1 /1 _ L 1 /7 <br />.." I Title Title tryski.orgeri441-4 Date .‘ Z ac.2 f gned x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />Sphcatton Accepted By <br />rout Inspection By AAN r -01.---- <br />estruction inspection By <br />DEPARTMENT USE ONLY <br />Date Issued 71-2-31C )/ Area <br />Date ,4-32,ic, Final Inspection L 4 Ai1ACLL-tDate(f~/(Y'- <br />Oats <br />OMMENTS I CONDITIONS - <br />_ <br />ACCOUNTING ONLY. AlDil <br />• FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK I REC'D BY DATE 7 „a • - <br />, <br />INVOICE <br />3 Co c,, c 1 .0 c, 9 9 2- z.--Vo' SRI/ (-)0 6. ) ?_ <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C <br />NIT IV - 6/23/99 /sign bkp43/MI <br /> <br />TION •!, • II • • : <br />