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�uy4bt7�4 J.7 6 r Lr in rL.uum t'Aut bJ . <br /> WELL PERMIT APPLICATION FORK UNIT N <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD JUN <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 f1yVIRo <br /> (209) 468-3449 fR -/V I <br /> '0 MME q<41 <4 <br /> plication <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pp��� <br /> plication is hereby made to San Joaquin County for a permit to construct andiar install the work described_ This application is made in cf 46�Son <br /> Squirt County Development Title.Chapter 9-1115.3 and.the Standards of San Joaquin County Public Health Services,Environmental <br /> Health <br /> Divl n. <br /> / <br /> Z�SI $oir � City 'STOCI47roN ZicI5Z Parcel# /fog- <br /> =LL Location Z r <br /> tOPERTYOwner 11'e Qaff reitis Com+"+ ah ddress 0400 Mary1L,% AV-e. City s+• L�uishy+•ZipG31O5phone# 3l4 259-2013 <br /> 57 Contractor6RIEG DP.ZLLZ/ 6Address 950 �foWrRD CityiP44�3Lctt85165Phonett9zs 3l3-SBoo <br /> a"m9zA Phone# 6/6 28!'1552 <br /> msultant I Sub Contractor r-Wx(-ZP SOLVXCES Address ?!o W SA+VQ� 8449 RR-City�Li� <br /> 2 G E Section 2 2 <br /> IS Coordinates:X yy <br /> 121015-.150 ' •Y i� 7e G'�7 Township T�N Range <br /> (ORK TO BE PERFORMED: <br /> 'NEW WQ DESTRUCTION(choose type below) <br /> WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER') Q OVER-BORE <br /> Q SOIL BORING z Q PRESSURE GROUT <br /> IWELLa VW—i <br /> Other: SOILL. vikFo•R ey IZAC.7710AJ. <br /> ;OMMENTS: <br /> ;YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES Q NO W ELL CASING DIA: <br /> ]EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC []OTHER; <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SFALr__TREMIF TYPE TO BE USED: Q AUGERS QHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER APPROX.BORING DEPTH____Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q SOIL BORING 0 s <br /> Q OTHER: Q OTHER CONDUCTOR CASING PROPOSED. (�if YES,listpeefications here)'^ <br /> COMMENTS' <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> e work will be unty ornances. <br /> I herebynd ceftionsthat <br /> I have the San prepared <br /> JoaquntCountyhis lication Homeowner and <br /> th tlhaensed agents s gnature certifies the foldone in accordance withlllow ng3q/cerJouin tify haft in tthe performance f the work <br /> ON <br /> for which this permit Ls issued,I shall not i mptcytpe persons <br /> hos a formsn a ofubject to thework for which 'Sf Dem s Jssuof edlil shall ompjoy persons sornia-l' Contractor's rubJect to ing or sub <br /> contracting signature certifies the following:" certify P <br /> WOP.KERS'COMPENSATION cos of Cali rnia." <br /> * CAL 7H P TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> TitlelCompany 2 ilz�„T�7'1�1.4.s�� -plfL�S` ✓��t <br /> Signed x <br /> Print Name_ T10�� Da <br /> SITE FILE ADDRESSIWORK PLAN DAT <br /> • S2z� �� /�Yo 9'3 •!✓ate Pte' �'� ,.. `Zoct <br /> DEPARTMENT USE ONLY __ (_70Area 07S_�- <br /> Date Issued11 <br /> Application Accepted BY /' DateZ6/12 Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AIDfi <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD Y DATE/ PERMIT I SERVICE�y�EST# INVOICE <br /> 3,5-01 h 5/1.7/00 <br /> r-r,7 exD. WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). <br />