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06/13/2002 IS 46 2094683433 FIFTH F,-OOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA_, 957-02 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> pphcat.on is hereeby made to San Joaquin County for a Pemvt to construct andlor it rtab the work descnbed This application is mace in comPlrsrtce vAth <br />�n Joagwn County Development T+tle Chapter 9-1115 3 and the Standards of San Jo344w County Pubr,c Hoaltn Se""ces Emnro�n� �Health ID-vision <br /> L,rP�� C e� E✓�+ S+r-'e4t S �A�fcFa^ TP�� parcel# Il-g-oSQ--u3 <br /> TELL Locatfvn �_Crosx Street Z� Y <br /> ddress77S S�+car�e , ✓ eay ra r, Z,p,1E 7ZPhone# <br /> ROPE-RTY Owner °+! r^ <br /> l L ddress p.b.Gax �Una _�,ty �an ��D�—U�t�Phone7t -775-��-�3J <br />-57 Contractor o L -- <br /> F CC ./rron�.�c-�ecress Zia � s cf C�hrL�c't Phone* -b7-y3.S`^yQs0 <br /> ' <br /> ansultan I Sub Contractor Cn' "'a• I^ <br />)Is Coor•a,nates X <br /> Y Tow ship Ranqe Secuon <br /> vCRK TO BE PERFORMED <br /> p Ot=STRUCIION(choose type 4>'low) <br /> tJEW INEL 1 BORING(CPT GircOPR061= }iYOROPUNCW HAND-AUGER OT}f>=R') (�OVER-BORE <br /> ❑SOIL BORING a PRESSURE GROUT <br /> pWELL# <br /> other <br /> rYPE OF WELL CONSTRUCTION TYPE GONSTRUCTtON 51x1=CtRCATiOrtS Y NO WELL CASING DIA 1,-7 <br /> RING p HOLLOW STEM DLA OF BOREHOLE I[> MULTIPLE CASINGS 0 ES 0*T:0) <br /> CTICN lj AIR HAMMERIDRIVEN CASING THICKNESS -Y� TYPE ODM E TO BE USED V Q�GERSR (HOSE <br /> 3 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�O <br /> AIR SPARGE U PVSH POINT GROUT SEAL.PUMPED -(Yes 0 No (NOTE_ MAXIMUM FREE-FALL DEPTH IS 301 <br /> j) SOIL_GORING g RANO AUGER �PPROX BORING DEPTH -12pr BOLTED TRAFFIC 80X or STOVE PIPE <br /> OTH£R �o7e V'y�CONoUCTa t CASING PROPOSED?_(If YES hst spec,C'catrors`here) <br /> r <br /> A <br /> COMMENTS v Lrc/ <br /> 1 ! Y"st'4 o LiC <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I Hereby certtt}r that 1 nave Pretsared this appl�atron and that ttie work wdl be done m accordance vrrth San Joaquin County Ord,nances_State Laws.and Rules <br /> and Regulations of the San.leaquwn County Horneowner or Incensed agents signature certiFes the follawtng '!cerufy Thal An the perjyrmance o/tht work <br /> for wh,ch airs permit is rxsued,1 shalt nvr employ persons subject to WORKMAN'S COMPE'NSA7 0H Laws of Gshtornja.' Contractors hiring or sub- <br /> cantracung Stg,"azure ceRrrieS the fottawrng 't eerhly That L*the performance of the+Meru forwhrch this permIt 4 rssued j she►!employ persons subJect to <br /> WORKMAN S COMPE'NSA7'70M Lays of C000m0a <br /> /THE APPLICANT MUST GALL 48 FIRS 1N ADVANCE FOR ALL REQUIRED tNSP1=CTIONS <br /> Signed x � l <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued ea <br /> ApGbgtran Accepted ey Da[e <br /> Grout Inspection ay Date F,nal Inspection By <br /> Oestructlon Inspection By Date <br /> CQiNMENTS I CONDITIONS <br /> FAC. <br /> AC-COUNTING ONLY AJOX <br /> PE CODES FEE INFO AMOUNT RENtfrrED CHEcK1uCASH RECENEt)lay DATE pERMTTISERVICE REQUEST NUMBER INVOICE <br /> 3s d( �f� oo ZSJ � �IOgZ' <br />