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's <br /> WELL- PERMIT APPLICATION FORM UNIT IV <br /> IZT�t .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> JUIN 5 2 ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD ) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> rl�v►i �IMENTAL HEALTH (209) 468-3450 <br /> PEt�N11T/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Revelopment Title,Chapter 9-1 1} 3 and theS nda�ps-pf San Joaquin County Public Health Services, Environmental Health Division. <br /> e Sf Q c Yd ss 7�yr, 3�U� ��51f` _ Assessor's <br /> � � -T, Cross Street W ,q ( I City �J� 6) Zip S� Parcel# <br /> 'NEL Location // <br /> o ress r City ' P4S Phone#�b6Aq5 <br /> ROPERTY Owner k I K G- S�12 i b Uae `'36,6,c_��[�S S Zi <br /> �7SI: ��Qn)F� TZD CitY W11T-I1J&Z�p�U�&5&A07one Z' l3 OD <br /> C-57 Contracto& EL-2C-2 1 Kl S 1 Address <br /> ( � � <br /> 0/2- <br /> -hr <br /> - LifZ Phon # 36. -: <br /> Consultant/Sub Contractor 1275 P� )�' Ci 1)i �S <br /> SIS Coordinates:X Y Township Range Section <br /> `NORK TO BE PERFORMED <br /> tl�rEW WELL/BORINGCPT}, GEOPROSE, HYDROPUNCH, HAND-AUGER. OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 0 WELL# &PRESSURE GROUT <br /> er: _ <br /> COMMENTS: �9(Fi 17 fV i� ( A i(x ? ��t L c ce c vor s iriiA— 300 Cis c a <br /> J <br /> _ CONSTRUCTION TYPE CONST RUCTIONSPECIFICATIONS <br /> j MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: <br /> TYPE OF CASING: STEEL PVC OTHER: <br /> J <br /> EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS 0 0 � <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE'YPE TO BE USED: 0 AUGERS 0 H 0 S E: <br /> 0 AIR SPARGE 0 PUSH. POINT GROUT SEAL PUMPED: 0 Yes .3 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: G P,1- CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> nereby certify that I have prepared this application and that the worK will be oone in accoroance with San Joaquin County Jrainances, State Laws, and Ruies <br /> and Regulations of the San Joaouin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> ,or which this permit is issued,!shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contracor's hiring or sub- <br /> -ontracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WCRKMAN'S COMPENSATION Laws of California." <br /> T ICANT��MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x rC � . Title T <br /> SEE SITE AP IN UNIT IV WORK PLAN. DATE z l/ s J <br /> DEPARTMENT USE ONLY <br /> Aoolication Accepted By. � — Date Issued 6, Oy Area <br /> 3rout Inspection By Date Final Inspection By Date <br /> Destruction Insbection By , QG Date <br /> COMMENTS I CONDITIONS � s �p rLt <br /> (,S V-U-777 <br /> (o -�v,6-<�►-l��i 4 <br /> FAC# <br /> l ACCOUNTING ONLY: AID# <br /> i <br /> 'I PE CODES FEE INFO AMOUNT REMITTED CHE #/CASH I RECEIVED BY DATE I aERMIT/SERVICE REQUEST NUMBER i INVOICE <br /> SR# `r <br /> UNIT IV-5/99/MI 7 / —3 �- <br />