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WELL PERMIT APPLICATION F .RM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 'Q1 RUG 23 An 11)&47 .)vm. E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <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 3905 Ajtity t;or. Cross Street City r • City cf-ot(141)11, Zip Parcel# I .-043D "03 <br />PROPERTY Owner5Se0 of;"44 y AddreSSeibtic Sit4del ert:(1.14% City,50.44 Sivi;,,)fZipq 0 61-0 Phone# <br />C-57 Contractor fQ j Drit(i1413 Address1q0 UOV4 CityKkrtetzipqt1555 Lic#14.135/K phone#R2.033 -S800 <br />Consultant / Sub Contractort6(40K6010A AIWA Address501( Cy(ie,t 100144 i/dicibi,;( Dorc4otiL(:LVA30. Phone#61 --/6/4> <br />GIS Coordinates: X Y , Township 1 Ai Range 66 Section <br />WORK TO BE PERFORMED <br />pAcIpW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />, 0 SOIL BORING # <br />0 WELL # <br />*Other: Z. let? ca <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT k4.114i,G.Q,( <br />TYPE OF WELL <br />o MONITORING <br />0 EXTRACTION <br />O VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />Kc)TH ER:tkpleGix <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER C4,bk41---44 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? U YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') \S <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE \ <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> <br />COMMENTS: 2- ro robe's 4-t A. ;0 <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: "/ 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) PLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x (A4-i Title 60 fl DI Z.425/Siel'ej 62.01. Date */ Z/0 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: gaf ikkeax/(Aa-d <br />DEPARTMENT USE ONLY <br />Date Issued rliD Area <br />Date Final Inspection By Date <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICEUgT # INVOICE <br />3rOI -47- n- -715(1 14-1.,_ fllem -1Rit 610.3-7 9-7 C--- <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &\VORI<ERSNAIONDECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />(-1/fia c