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+ lat., . <br /> WEL6"mo-'ERMIT APPLICATION FSM UNIT IV <br /> SAN JOAQUIN COUNTY PUI3,LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DivlsbN (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 Counly for a permit to construct and/or install the workldeseribad. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin Courtty Pubfic Health Services, Environmental Health Division. <br /> ` ' Assessor's i <br /> WELL Location 3ti�� ARXa-wi2�..:, cross StreetQ^-r .5 1-j City ,oc.1-M!t Zip!-4 Parcel# <br /> PROPERTY Owner 0-t'>, P-i-t-S-i-ay `�Vrcr�Address ?a5� �x�igj 04WdCit�y�. Xlrva�S , /9CI Phone#91(.373-$JOZ <br /> 1 <br /> C-57 Contractor t.�+�n. Address Z3 wwr-.lir', Cit li�an>i Z'i -Uc#SIT.LC.St�honertL �8�12 <br /> Consultant/Sub Contractor(,fsv�w�f � S Address.Cl$.i f r..,ar fir, to CityrstSA a Lic# Phone#G_7L_ •3q6-I`3D <br /> GIS Coordinates:X ,Y Township Range Se tion <br /> 4 i <br /> WORK TO DE PERFORMED �{ <br /> 1 il <br /> i I NEW WI=LL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER•) + []DEST choose type below) <br /> salt BORING# <br /> �r <br /> � ,-N G ., ..._.�. a 0 OVER-SORE <br /> „ 0 WELL# I PRESSURE GROUT <br /> 'Other. '"e. S Ia.7 ^' Z'7 �®— � e_---r- <br /> COMMENTS: <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i{ <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE SMULTIPLE CASINGS? a YES I NO WELL CASING DIA: <br /> a EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING; a STEEL p PVC a OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL. -Z-t +-., TREMIE TYPE TO BE USED: l AUGERS CHOSE <br /> D AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: B Yes p No (NOTr`!<: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> I SOIL BORING A HAND AUGER APPROX. BORING DEPTH Z7 -� Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> a OTHER: D OTHER CONDUCTOR CASING PROPOSED? N10 (if YES,list specifications here): <br /> T <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: "I certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPE'NSATION'ILaws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the perlormanGe of thg work for which This permit is issued. I shalt employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." It. <br /> CALL-THE UNIT IV INSPECTOR-48 WORKING HRS IN ADVANCE�FOI2-'ALL-REQUIRED INSPECTIONS. <br /> Signed N��- Title/Company �—ow I nw, te-•PCT-t-5 <br /> Print Name _Date i <br /> s0 d0 i <br /> SSE rfSkTMAP iN ?U� T� I w �'PL1N ,RATI . <br /> DEPARTMENT USE ONLY. l <br /> J i Application Accepted By V __Date Issued Area Z-9P <br /> Grout Inspection By Date Final Inspection By.., Date ; <br /> Destruction Inspection ey Date <br /> COMMENTS I CONDITIONS: I'. <br /> ACCOUNTING ONLY: JAID# <br /> FArlft <br /> Ir <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK S RECD BY DATEPERMIT I SERVICE REQUEST# INVOICE <br /> 10S2, LSD zzq 3 Z <br /> 1/18/2000 <br />