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WEL6*0 'ERMIT APPLICATION Fs,, ZM 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 /> 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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> ff Assessor's <br /> WELL Location 45 t�42 SGS Cross Street ',^ -City jE&C Zip.• 1�.ri-S,2,6Percege A9►�-D j�-Og <br /> 2ROPERTY OwnerAle-&W �l►'- .�� Address��3 FAL.AaC-tY ZipgS32�Phone#�S�S�► 2 <br /> -57 Contractor Address &00A'&Y 5 CiryRWUS�% Zip&E2lUc/Ui2FaMPhones}/4-2.9�L <br /> Consultant/Sub Contractor Address ����b'L_C►tYRJ rPhone>:�09 S9?E7tiL <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> PEW WELL/BORING(CPT, GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING s 3 **A" OVER-BORE <br /> WELL a Q PRESSURE GROUT <br /> '7ther. <br /> :OMME S: <br /> 'YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS $ds. C%VV -4 <br /> 3 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA: <br /> 0 F-XTRACTION a AIR HAMMER/DRtVEN CASING THICKNESS TYPE OF CASING: (] STEEL Q PVC Q OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS QHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: <br /> CONDUCTOR CASING PROPOSED? (if YES.list specifications h <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROA ERMITS! <br /> I hereby certify that 1 have prepared this app)icatbn and that the work will be done in accordance with San Joaquin%ulwy Ordinances, State Laws.and Rumes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agents signature certifies the following: "I C@rdyy that in the performance of the work <br /> for which this permit is issued.I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br /> ;ontracting signature certifies the following: .1 certify that in the Prrdon"arne of the work for whrCr,this permit is issued. I snail employ persons subject to <br /> AMORKMAN'S COMPENSATION Laws Of CaldbrWa.' <br /> T APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Date / L- 42� <br /> Signed x <br /> SEE SITE MAP I UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued t is I O C2 Area <br /> Application Accepted By <br /> 1 , �....�p� Date OO Final inspection By Date _ <br /> Grout Inspection By J1 Y <br /> Destruction Inspection By Date <br /> ZOMMENTS/CONDITIONS: <br /> I <br /> PAC# <br /> ACCOUNTING ONLY: AID* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY i DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3-501 <br /> UNIT IV-5/99/MI <br />