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� <br /> I <br /> WELLERMIT APPLICATION F( M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton; CA.,'95207 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YLAR FROM DATE ISSUED <br /> # Appiication is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chaplet 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assesst WELL.Location - <br /> `31'3 PAM "��^� Cross Street QNTK!. i►�I City ��"'�"�"�'`1 zip�s�l� Parcel# <br /> PROPERTY Ownery•�,�ag�rad ` rcc�Address _S.L Nd�]r7TrrA r 1uc�City�• +�1rr, Phone#glt.-✓13"SIa Z <br /> { li <br /> C-57 Contractor �J�4aEc'�Tr-►+^^- Address Z3 www-+ 0 r'. Cil +�+s ZixgA Lc#SlT1C►gPhone#�1��`{G�872 <br /> I <br /> 'i Consultant Sub Contractor Address(­1S$+Loc.-ay-,­5r.*10 city��AQ64a Lice '"� PhoneSG2L• G-!`F�C7 <br /> GIS Coordinates;X Y' Township Range Section <br /> WORK TO BE PERFORMED ;f <br /> VV <br /> II NEW WELL!BORING(CPT.GEOPROBE, HYOROPUNCH, HAND-AUGER,OTHER') p REST I'J �ON choose type below) <br /> SOIL BORING A N• JC_- OVER-FORE <br /> i q WELL It ; 0 PRESSURE GROUT <br /> 'Other: r tee. E <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 5PFCIFICATtONS <br /> a MONITORING I H04LOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS? a YES I NO WELL CASING DIA: <br /> a EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS T PE OF CASING: 0 STEEL (}PVC d OTHER; `— <br /> Q VAPOR U MUD ROTARY DEPTH OF GROUT SEAL C TREMIE TYPE TO UE USED: R AUGERS DHOSE <br /> a AIR SPARGE 17 PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> { 11 SOIL BORING 11 HAND AUGER APPROX.BORING DEPTH Z-7 A . a BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 'f d OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? 'a (if YES,list specifications here); <br /> i <br /> COMMENTS: <br /> r NOTE: OFFSITE BORINGS'REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that tha 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: "1 cortlfy that in the performance of the work <br /> for which this permit Is Issued,f shalt not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify thef in the porforman;e of the work for which this permit is issued, i shsu employ parsons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL.THE UNIT IV CTOR'48 WORKING HRS IN ADVANCE F0k,-ALL_REQU1RE.D INSPECTIONS. <br /> ! 1 ti <br /> Signed Title/CompanyL-owra�,.t f--\"��^C-.r—5 <br /> Prink Name rbGK � `EI^L Date <br /> ,s <br /> SEE Print <br /> ITI MT <br /> AF' -IN t: l � � (V j "Al <br /> , P dly DATA w r r, r fl , <br /> ..—r,r.,...t.kl...-.-..4fn.A r.fn+Y .�.••••r..1.,,...l�.Wf...wa...wwr r. wJ�.r_.4..-..f .A..n.Ja.l. .r�r.�w-w�mnn�nr. 51••1.,y <br /> DEPARTMENT USE ONLY <br /> Application Accepted By4_QDate Issued �I`y,F7 „_,-,Area Z9 P <br /> !, <br /> Grout inspection By Date Final Inspection By Date <br /> # Destruction Inspection By Date <br /> COMMENTS I CONDITIONS,. ' <br /> 'i <br /> ACCOUNTING ONLY: AID# FACU <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD DY DATE PERMIT 1 SERVICE REQUE5T 9 INVOICC <br /> 1/18/2000 <br />