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WELPERMMAPPLI ATION rJRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLI HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EH � 1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34,19 APR 0.7 � <br /> ENVIRON �IV7 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDp�A �tL oe <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap tiCzfil , s✓6 �i to p once with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmen6rHeaith Division. <br /> i <br /> Assessor's <br /> WELL Location 200 S. Cherokee Cross Street Lodi Ave. city _ Lodi ,CA zip95240 Parcel# <br /> PROPERTYOwner HenryA. Hansen Address 652 E. Pine St. city Lodi , CA Zip 95240 Phone# <br /> C-57 Contractor to be determined Address ity Zip Lic# Phone# <br /> Consultant/Sub Contractor Stephen .,G: Muir Address P 0 Box 152 cityWDodhridc1Q# CA 952 hone# 209.369-9421 <br /> i <br /> GIS Coordinates:X Y Tdwnshi 3 <br /> p Range �� Section 6 <br /> WORK TO BE PERFORMED <br /> XNEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> Q WELL# 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> Contractor will be determined after bidding <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES o NO WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC 0 OTHER: <br /> ©VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ]HOSE <br /> U AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: a Yes t1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> tI SOIL BORING o HAND AUGER APPROX. BORING DEPTH <br /> IJ BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROP SED? (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 dertifies the following: "1 certify that in the performance of the work <br /> for which this permit is issued,l shall not employ persons subject to WORKERS'GOMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "t certify that in the performance of the work or which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE.UNIT IV INSPECTOR 48:WORKING HRS IN Ab ANCEfOR ALL REQUIRED INSPECTIONS. <br /> Signedx 4[-rite Title/Company P esident - RIGHT WAY, INC. (Property Mgr. ) 1 <br /> Print Name James J. Verseput Date /5/00 <br /> SEE S1TEMAP IN UNIT !V WORK PLA DATED• ' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> Area <br /> Grout Inspection By Date F nal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# I i <br /> FArft <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />