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��� � �''��'�� ���, UNIT IV <br />Vh _LL PERMIT APPLICATION ORM � �•�1,:� <br />SAN JOAQUIN COUNTY PUBLIC HEALTH ,VIC' �g- <br />ENVIRONMENTAL HEALTH DIVISION ("PH ,_ 1�i 1,99 <br />304 E. Weber, Third Floor, Stockton, CA., 954' `'AUT '9 <br />(209) 468-3450 .1144 , F� T <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C�& <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' <br />rcel# s KI <br />WELL Location CrossStreet O�A —City <br />PROPERTY Owner C 5 5 Cc,10 r � c f i00 ,�} Address 6 3 5 �- C In,/ 5 Z City 5 )CC100i,, )Oin Zip Phone# H 5 �' 7 0 1, <br />C-57 Contractor 10ya V r Id 6 obl o v,'w:, Address `1 �'' % IV _ IAI,150 1, Wu Y City 5 11, r ll jc ,n Zpg S fir' i Lift ( b-; ?17 Phone# E 7,16C ( <br />u' <br />Consultant /Sub Contractor 1�;1 r 1, r l I pr; I l i 4Address f o• �'0 2 I City fmg,k6 /� ud tiG 6 7 7-6 I 1 Phone# 3 436 "'166 0 � <br />GIS Coordinates: X . Y Township Range Section <br />WORK TO BE PERFORMED -" <br />tj NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER -BORE <br />WELL # 0 PRESSURE GROUT <br />^ <br />"Other. <br />CCMMENTS: <br />u <br />YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING S HOLLOW STEM DIA. OF BOREHOLE S MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: <br />0 EXTRACTION <br />VAPOR <br />AIR SPARGE <br />SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 U It1tK <br />0 MUD ROTARY DEPTH OF GROUT SEAL T I% TREMIE TYPE TO BE USED: GAUGERS 0HCSE <br />0 PUSH POINT GROUT SEAL PUMPED: 11 Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER APPROX. BORING DEPTH (, (, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? w ( if YES. list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br />nereoy 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: "l certify that in the performance of the work <br />for which this permit is issued, t shall not employ persons subject to WORKMAN'S 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, / shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />,w� �LC,�•/� itle I I c �oW;'S I Date I / 7 I <br />Signed x ,t ✓n <br />SEE SITE MAP IN .UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY G C/,- <br />` r Date Issued / Area .SJ C' <br />Application Accepted By <br />Grout Inspection By <br />Date <br />Gi Final Inspection By Date <br />Destruction Inspection By ` <br />Date <br />COMMENTS !CONDITIONS: <br />pY► <br />L <br />�' , Gi?'i " C. 6 <br />FAC# <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK91CASH <br />I RECEIVED qY <br />DATE I PERMI LEiVlLa R ST NUMBER <br />INVOICE <br />UNIT IV - 5/99 /MI <br />J / k,- <br />