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09/15,199 t9F.D 13::37 FAX 5 1 0 66=" 63S0 GFIONATR i 1 OAKLAND <br /> WtvtL PERMIT APPLICATlaI~ f'ff4r,R_ -_ ' µ 6 I IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV��PSJ 7 1999 <br /> ENVIRONMENTAL M TAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CLAN\95233$;VIEN ! <br /> {209T468-3449 PERMIT <br /> NON-REFUNOAQLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> ADpk2tion is hereby made to San Joaquin County for a permit to construct and/yr inslaH the work described. This application is made in compliance with <br /> San Joaquin County Development T'R3e,Chapter 9-11115.3 and the Standards atSain�Joaquin County PuWtc Health Services,Environmental Health Diviswn <br /> WELLLocat3on�� W• Ilia �J Vyc' t CratsStre-_t Ifarmf kow-city Zip li3-77t, Parxw?7iZ-I JD—fl7 <br /> PROPERTYOwner POWiP12 P\4ej±j Address I')5S W. Ilt�t 1ftreef City-C &I 0•53rv_PhonNtW4g-EH-gI9' <br /> Cd37 Contractor r o(jrj� LAddress I�D 1j, 1-90fl, SJt City PiZip Liclf 'Sfoi PhoneN X10- -�J��` <br /> Consultant r Sub Contractor 13V1D1'bl'7 x Address2t0l rAll!jc,•_GC(2*'I_, C'fij. Lialt _Pfiane# 3-1{I DO <br /> GIS Coordinatcs:X 3-r??6t Y-IZI.444-Ie TowraNp Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL/BORING I CPT,GEOPROSE,HYDROPUNCH.HAND-AUGER OTHER) (I DESTRUCTION(choose type beiaw) <br /> SOILBORINGrf sit—&2O 0OVER-GORE <br /> Q V'JELL A Q PRESSURE GROUT <br /> -Otttar, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DtA.OF BOREHOLE_MULTIPLE CASINGS?0 YES 13 NO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAWRl4ERMRIVEN CASING TH ICMESS KA TYP1: OF CASING: (ISTEEL Q PVC p OTHER:_ <br /> Q VAPOR 0 MUD ROTARY OEM OF GROUT SEAL N A TREMIE TYPE TO BE USED: 0 AUGERS ;3�10SE <br /> 0 AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: Q Yts )ENo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ',SOIL BORING Q HAND AUGER APPROX.BORING DEPTH I, -reet 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER: ft OTHER CONDUCTOR CASING PROPOSED? Sit. (if YES,listspeci fcations here): <br /> COMMENTS.—ID 6e,31oorti 5 j ob'U'_sa Z1--•-`M eccdi r.L6 S"V- _ 1_66VC309 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that Me work W l be dote in accordance with Sart Joaquin Comity Ordinances,State Laws,and Rubes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agenrs slgnatum cartirw&the foitvwing: -t cormY that in!Ae performance of Yto work <br /> for whhh this perni t Is Issued,l shall not eraptor persona subject to WORKERS'COMPENSATION Laws of CafifvrWa." Contractors hW9 or sub- <br /> contracting signature cartifies the toSowing:'I cgt*that kt the perlbrmarrce of the Quark Ibr whkh this pwmk is hatred.I Shalt employ persons a4lecd m <br /> WORKERS' SATION Lawn of CoMbrrda.' <br /> THE AP MU37 CALL 48 HRS IN ADVANCE FOR ALL REOUIR�E.,DD INSPECTIONS. <br /> Signed x �� <br /> SEE SITE .MAP I UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Appticatfan Aoceptcd BY Date Issued l 7/ Area <br /> Grout Inspecltan By Gate Fi al Inspection By Date <br /> Destruction Inspection By Date IC <br /> COMMENTS/CONDITIONS: •Z' c,6 <br /> - <br /> FAC* <br /> ACCOUNTING ONLY: A(00 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKAWCASH RECEIVED BY DATE Pt�lItTISERVICE REQUEST NUMBER INVOICE <br /> 2 <br /> _...� . <br /> UWTIV-6/23/99/sigZ bkpg/AAI <br />