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WELt"'PERMIT APPLICATION FSM 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) 468-3450 <br /> r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> W _ <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 61 plianCCilith <br /> San Joaquin County Dev <br /> elopment Title.Chapter 9.1113.3 and the Standards of San Joaquin County Public Health Services,Environmentals ea'"Division. <br /> WELL Location V t��" Cross Streets . City Zipf5j20 ParceW <br /> PROPERTY Owner 'LdAhourtS Address1 n t k&City Z•ipg"Z&honert $- 3432 <br /> 57 Contractor ?C is'l4� Address�X r9 I is <br /> City pfcs 2j~hon - <br /> Consultant I Sub Contractor <br /> Address dIQJS��c�2&jjfl City LcPhone# <br /> Y Township Range Section <br /> GIS Coordinates:X - - <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT. GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER') aDESTRUCTION(choose type below)l]OVER-SORE <br /> Q SOIL BORIN R PRESSURE GROUT <br /> Other. G ze <br /> COMMENTS: �Y OL w <br /> 'YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> rMONITORING /,HOLLOW STEM DIA.OF BOREHOLE'* W' MUL`i1PLE CASINGS?a YES 8-NO WELL CASING DIA: <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Yy TYPE OF CASING. a STEEL /eISVC Q OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 4. Gd TREMIE TYPE TO BE USED: Q AUGERS /S�IOSE <br /> PUSH POINT GROUT SEAL PUMPED: Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE O <br /> Q SOIL BORING a HAND AUGER APPROX.BORING DEPTH 70 BOLTED TRAFFIC BOX or 0 STOVE PIP_ <br /> Q OTHER: <br /> CONDUCTOR CASING PROPOSED N ii (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 sone t accoroantx with San Joaq County aOrdinances,heLaws.a d Ruses <br /> e work <br /> and Regulations of the San Joaquin County. Homeowner or l;ccensed agents signature certifies the totlowing: " P <br /> for which this permit S issued,!shall not employ persons subjea to WORIUNAN'S COMPENSATION Laws of California." Contractors h dor sub <br /> - <br /> and <br /> signature certifies the tollowing: 'I certify that in the pwrtormarroe of the work for wnlcn this permit is issued. 1 Sha!!employ persons <br /> cMORKMAN'S C MPENSA71ON Laws of Calit m&' <br /> AP ICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title Gs `�`^' Date '- .--- <br /> Signed x <br /> SEE SI E MAP IN UNIT IV WORK PuLA�N`YDATED I, �C <br /> DEPARTMENT <br /> Date Issued Area <br /> Application Accepted By O Final Inspection4syGrout inspection By Oate - <br /> Desatmlion Inspection By Date <br /> 4 <br /> ZOMMENTS I CONDITIONS: <br /> FACtr I <br /> I <br /> ACCOUNTING ONLY: AID* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOICASH RECEIVED BY DATE PERMI7ISERVICE REQUEST NUMBER I INVOICE <br /> G, � q�� i \ U� bb 0 A b <br /> UNIT IV-5/99/MI <br />