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TYPE OF WEL4. INSTALLATION TYPE <br />ONITORING • tIOLLOW STEM <br />fl 4 gXTRACTItis: C\I fl AIR HAMMER/DRIVEN <br />VAPOR .-,--;•*Ct. X MUD ROTARY <br />Q.. fl AIR SPAR9E--... D PUSH POINT <br />SOIL BORR,314:: c`j 0 HAND AUGER <br />OTHER: OTHER <br />COMMEN47 Cr) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g“ MULTIPLE CASINGS? 0 YES <br />CASING THICKNESS56-6. 40 TYPE OF CASING: I] STEEL VC 0 OTHER: <br />DEPTH OF GROUT SEAL 5o' TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br />GROUT SEAL PUMPED: 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />)(BOLTED TRAFFIC BOX or STOVE PIPE <br />Z " NO WELL CASING DIA: <br />APPROX. BORING DEPTH 7-5 <br /> CONDUCTOR CASING PROPOSED? 1,1 0 ( if YES, list specifications here) <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: "I 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 />I 'CANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />2 .CL444467 Title relt-.1 5 Date / (o 3 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By, V I; G-17DY:10,-. M C.. Ca 11—bl.. Date Issued ec, -2 4 6 3 <br />Grout Inspection By '-&,e7tilet-LW/44,/i--127 Date 3/ d 3 Final Inspection By <br />Destruction Inspection By Date <br /> <br />Area <br />ate 7/s/cis <br /> <br />TH <br />Signed x <br />WELIVERMIT APPLICATION FARM <br /> <br />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 />WELL Location (0 2,0 al‘k_ AVe 50 tQftl. Cross Streets 1 M44:el e.---City SIDe-144% Zip <br />Assessor's <br />Parcel# 1 S 7 - 2.4 41. -2.2 <br />PROPERTY Owner (Q14114-42 t444,4(.P1t s Address te991--64401knie-eyi- • City M2(44.014/1- eliip q14-539 Phone#(5i 0)04 ^gc00 <br />C-57 Contractorf Peit(1444) ./S*InAddress 15D140/J4 ad .City at z pq11%5Lic# r 4 41(65 Phone#NS)3/3'SgO° <br />Consultant / Sub Contractorttfel-0104/11(cm‘s40444Address501( 60the"i6t7L-1( frit./ C tIt P - -.AL. , % liS 16 5 301Phone# (q1(0)1 3‘t —2(1-ci <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />N ./NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />*Other: <br /> )./ELL # <br />O DESTRUCTION (choose type below) Q OVER-BORE <br />fl PRESSURE GROUT <br />COMMENTS: <br />COMMENTS! CONDITIONS: 1)1 \ 73(110ft; 0 rio4 3 u we, fey YO Y1 :+1) w e 11 MW - 1 • <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT r : * ES • INVOICE <br />SR# 0 0 3 4- 3 2 1 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS CLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI