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Application Accepted By <br />Grout Inspection By ----ill, Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: ieos <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # <br />356 f.'2 ?3 52'8 13 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />sR# <br />DEPARTMENT USE ONLY <br />Date Issued <br />O 2---Final Inspection By <br />It4(4( 's -1 <br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <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 <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 />Parcel# Ret,u <br />PROPERTY PROPERTY Owner (.11-',/ oC• 5 -1,. .1,6, Address `4 2. 1'4. El porwao S. . City SAN.c-‘0-o," Zip 95202 Phone# 20 9- 93 7 -83449 <br />C-57 Contractor wc.,), v.ra Oct itly. Address TO to,e 336 Cityikto \Ask. Zip 9 14611 Lic#T10071 Phone# 707 - 314 -1430o <br />Consultant / Sub Contractor Day ter t).1 . %-kr -s., Address It•it, Ci.1c1Co...? Pr,/ 17o CityRanctlo Civecla•Lic# •721t Phone#116- 631 - 17oo <br />GIS Coordinates: X , Township Range <br />WORK TO BE PERFORMED <br />KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />KWELL # 2,0 <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />PRESSURE GROUT <br /> <br />*Other: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />4/MONITORING lir,HOLLOW STEM <br />0 EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR flMUDROTARY <br />BAIR SPARGE fl PUSH POINT <br />P SOIL BORING 0 HAND AUGER <br />OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8" MULTIPLE CASINGS? 0 YES 100 WELL CASING DIA: 2 " <br />CASING THICKNESS 5 c.k c/C) TYPE OF CASING: fl STEEL X\PVC f OTHER: <br />DEPTH OF GROUT SEAL 7 83 I TREMIE TYPE TO BE USED: 0 AUGERS *OSE C" <br />GROUT SEAL PUMPED: f&es f No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 60d 'le VBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N ( 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: "/ 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 California." <br />T AP LI ANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />2.7 1 3 /02- <br />Title Se Y‘ 0 G eo ‘$ Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: Deceml3er ZOO <br />WELL Location 18 0 5 ft L4 1, PactPte. Avcnve- Cross Street Wo.1no4 54. City 5k-oe..146,41 Zip <br />Section (5.c\ <br />Oc <br />Signed x