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ii <br /> I i WELL PE <br /> RMIT 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. , 95202 <br /> (209) 468-3449 <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 Development Title, Chapter 0-1115.3 and the Standards of San Joaduin County Public Health Services, Environmental Heanh Division. <br /> WELLLocation 749 E . Charter Way crossStreetGrant Ste city Stockton Z;p95202 AssessoParcel# x147 - 343 - 09 <br /> PROPERTYOwner Benetorinc . AddressP • O . BOx 980220 W . Sac 95798 9166770819 <br /> City Zip Phoney <br /> C-57Contractor SPXXX Spectrum Address 2365 Wigwam Dr . c,,y tockto> . 952Q55 51221p� Ron so 465 - 8712 <br /> Consultant ! Sub Contractor CA Geophysical ( CgWjs P . O . Box 578341CifLict <br /> Modt C P6506R2095271247 <br /> y esp hone# <br /> i <br /> GIS Coordinates: X , Y_ Township Range - Section <br /> WORK TO BEPERFORMED <br /> 0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING R <br /> ELL # MW- 0 OVER-FORE <br /> "Other: HO11 oyg DS Wrmr Auger O PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XjtMONITORING )9XIOLLOW STEM DIA. OF BOREHOLE 8' . _ MULTIPLE CASINGS? <br /> DYES [ NO WELL CASING DIA: 2 " <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS '40 TYPE OF CASING: 0 STEEL )PVC 0 OTHER! <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 27 Ft e TREMIE TYPE TO BE USED! [] AUGERS XMiOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: XO{Yas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3o') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 50 Ft-,___$BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 6 OTHER:.0 OTHERCONDUCTOR:CASING PROPOSED? ( if YES, list specifications here):_ <br /> COMMENTS: <br /> i <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 oedifies the following : "/ certify that in the performance of the work <br /> for which this permit is issued, i shall not emp/ay persons subject to WORKERS' COMPENSAT/ON Laws of California. " Contradtdr's Hiring or euh- <br /> contracting s re pertities the following: '•I certify that in the parformanoe of the work for which this permit is isaued, / shall employ persons subjeCf to l <br /> WORK ' COM NSATION Laws of Califomia. " <br /> THE APPLICANT M' ST ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> Signed Titla_��Yj— Dale (L�L( �OT <br /> SEE SITE MAP WORK PLAN DATED Oct . 16 , 2004t <br /> �� �� DEPARTMENT USE ONLY <br /> Application Accepted By /UCjl.�(0i/S/ h nate Issued 071159 of eee� Area <br /> Grout Inspection By <br /> Date_T Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> sz 533 (�� 398G 0041312lp i <br /> C=57 LICENSED CON'TRAC'TOR MUST-SIGN LICENSE &YVOI'iTiERS' CO.111PENSATION DECLARATION <br /> UNIT IV - 6/23/99 /sign bkpg/MI <br />