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I / -U I - I .`-+`_i`_i . `;FYI' rKUrI P . <br /> li <br /> � p WELL PERMIT APPLICATION FORM UNIT IV <br /> DAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> JUL 2 12005 ENVIRONMENTAL HEALTH DIVISION (PNS-EHD) <br /> ENVIRONMENT HEALTV1304 E. Weber, Third Floor, Stockton , CA . , 95202 <br /> nRMITISERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 9-1116,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Sidewalk of Assess r <br /> WELL Location rg N r}f side crossstroetCharter WaM Stockton Z,. 95202 Parcel#o1 X734309 <br /> 0 56070MP <br /> PROPERTYOwnar. eneto , Inc . Address Pw0wBoCis x980220 'V . Sac Zip 95798Phoney 9166770819 <br /> G-57 Contractor Spectrum Address 2365 Wigwam Dr . city StocktQp 952Qi5 5122 � lone#465 - 8712 <br /> Consultant / Sub ContraotorCA Geophysical ( QgGjs P . O . Box578341 CityModestoLi 6506Rjhone#2095271247 <br /> GIS Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED — - - <br /> 4NEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER*) - 0 DESTRUCTION (choose type below) <br /> 0 SOIL 8QF) 9 R OVER-BORE <br /> LL # 0 PRESSURE GROUT <br /> "Other: "isMako 21nd - C�.�fa� <br /> COMMENTS: f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> XIKMONITORING JIIOLLOW STEM DIA. OF BOREHOLE $ =-$ MULTIPLE CASINGS? 0 YES ?t} NO WELL CASING DIA: 211 <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING 0 STEEL QVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 27 Ft . TREMIE TYPE TO BE USED: 0 AUGERS )IOS'e <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: g&as p No (NOTE: MAXIMUM FREE-FALL DEPTH is 301) <br /> 0 SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 50Ft . }gp$OLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER: fl 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 : `9 certify that in the performance of the work <br /> for which this permit is issued, / shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub• <br /> contrac ' siyn lure certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ parsons subject to <br /> WOR ERS' COtYPENSATION Laws of Cafifomia." <br /> yY THE APPLIC T/,�UST CALL 48 HRS IN ADVANCE/FOR ALL REQUIRED INSPECTIONS. <br /> Title Gdt1 02ta �2 <br /> SEE SITE M IN J WORK PLAN DATED Oct . 16 , 2004 <br /> DEPARTMENT USE ONLY ` <br /> Application Accepted By a ,e F[�/, Iq Date Issued/ 2�r657 Area <br /> Grout Inspection By Date Final Inspection By Date_ <br /> Destruction Inspaotion 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 /> 35o / I <br /> 03 279 �` ✓?68 Cv K 7zfr1 0043239 <br /> C=57 LICENSED. CONTRACTOR MUST SI-GN::LICLNSE &WORKERS' CO3MPENSATION DECLr DATION <br /> UNIT TV - 6/23/99 /sign bkpg/MI COS, Revrc6 (elr �er/w+_l vs 05-- 0914/ <br />