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TYPE OF WELL <br />0 MONITORING <br />O EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />0 OTHER:yoen be <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />TTUSH POINT <br />0 HAND AUGE <br />0 OTHER <br />WEL _ PERMIT APPLICATION leRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />'01 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ric' no <br />fli304.toWeber, 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 <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location 61".(1ALP-clit-40 3cc/1 /4.1,avy Pr. Cross Street ts,b.vr przve CityfaiMel't Zip <br />PROPERTY Owner Of Viiii-A Et441lie )1,44 ‘fd-f it1.eAddresscNI 4I.WabeeAii 5-1eL4ID City 5415 440 14 CA Zipl4Z43 Phone#(20q) 491 './00 t i <br />C-57 Contractor 6 rat Pr; (C', Address 45'0 Howe gcl citArfino% zip6114553Lic#4.84165 phone#(q1..S)313-42o0 <br />Consultant / Sub Contractor tftflidItA 1,1Vti°0%tv.4./444.( AddresscOa‘011ett 'Odlit,i1( PdCWrit4(lbajagl!i46/314' Phone#010413/-2-40 <br />GIS Coordinates: X Y , Township 1 M Range (2 E Section <br />WORK TO BE PERFORMED <br />KEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />fl SOIL BORING # <br />0 WEL <br />*Other: 6 cl ef) 12,6,9 be &F I 2_) - 5 H- Me bta,,_„,( <br />COMMENTS: Li <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC fl 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') <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or <br />CONDUCTOR CASING PROPOSED? <br />( if YES, list specifications here) <br />COMMENTS: 3 fraqrvi)e-5 40 — 3f)`; 3 v.r., ix.„ <br />ctq.24K-4-4,-,1-ct+-cteAu <br />NOTE: OFFSITE BORINGS REQUIR ACCESS R ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will bè4Wcordance 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: "1 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 />TO) APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Titiettor:Zol, 11/2 .6e.D-62.rir Date 2-7-Y0 / Signed x / 5 t4.4;e4 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: S4wq.ve 4,4v44-(1 <br />DEPARTMENT USE ONLY <br />Application Accepted By /41('-s--0-t-f Date Issued O 1 Area (44.11"-i4C13 <br />Grout Inspection By4 et Date 0 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: , S <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE EST # INVOICE <br />/-1-14- <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS LARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Assessor's 3c,Ds <br />Parcel# API 0 30 <br />fl STOVE PIPE 1_52.. SoSZ.