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31 - 1990 3Pt1 FROPI R <br /> WELL PERMIT APPLICATION FORMUNIT IV <br /> JUL <br /> 7 1Q9 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEFRVj ftN1V1EN iAL HEALTH <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EWMIT / SERVICES <br /> 304 E. Weber, Third Floor, Stockton , CA . , 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 Development Title, Chaptar g-T 115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 845 E . Charter Way Assessor's <br /> WELL Location Y cross StreetGrant St . City Stockton z;p 95206Parcel# <br /> 3 ^ <br /> PROPERTY Owner Pep Boys Address W . Allegheny Ave . C;tyPhiladelp , 9.x32 phone: <br /> C-57ContractorFrontier Drillindress9333W . McDonald Cit�S ocktolyip9520 (icfi673501phoneo669 - 0211 <br /> Consultant / Sub Contractor Ca . Geo p hys ical AddremT . O . Box 578341 CityModestQic# Phone#527 - 1247 <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below/ <br /> Q SOIL BORING # n OVER-BORE <br /> O WELL # BM - 73 n PRESSURE GROUT <br /> other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )a HOLLOW STEM DIA. OF BOREHOLE 8 • 5 MULTIPLE CASINGS? 0 YES [(NO WELL CASING DIA: 2 " <br /> 0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESSP V C 40 TYPE OF CASING; a STEEL Xfl PVC a OTHER: <br /> 0 VAPOR 0 MUO ROTARY DEPTH OF GROUT SEAL7� TREMIE TYPE TO BE USED: U AUGERS SHOSE <br /> p AIR SPARGE g PUSH POINT GROUT SEAL PUMPED: B Yes EfNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING d HAND AUGER APPROX. BORING DEPTH Fitt Ft - IXBOLTED TRAFFIC BOX or a STOVE PIPE <br /> p OTHER: D OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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: `7 corilfy that in the performance of file work <br /> for which this permit is issued, I shall not empley persons subject to WORKERS' COMPENSA TION Laws of California." Contractor's hiring or sub• <br /> contracting signature certifies the following: 1 certify that in the penrormanee of the work for which this permit i's issued, I shall employ persons subject to <br /> WORKERS' COMPENSATION Laws of Califomia. " <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> Signedx Title President Date 7 / 2 / 99 <br /> SE9, <br /> SITE MAP IN UNIT IV WORK PLAN DATED 8 / 21 / 98 <br /> �j DEPARTMENT USE ONLY <br /> Application Accepted By l_-�.i"t-e eea� Date Issued 7 �y - j` 7 Ai ea 0 7 S( _ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED %tg.0ASHI <br /> RECEIVED BY DA/TE/ PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3S0 , ur / S�3 �! �/ SR# <br /> C-57 LICENSED. CONTRACTOR MUST SIGN=LICENSE &WORRERS' COMPENSATION DECLARATION <br /> VWT IV - 6/23/99 /sign bkpg/MI <br />