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UXLWNAL <br /> ELL-PERMIT APPLICATION FU-RM UNIT IV <br /> DILE FI L \J11 /// l <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES /��%� l�� <br /> MAY 0 5?000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ,:-_i'JVIRONM1E;JTAL HEAEIH' , <br /> n4 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 12. <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 /> [ 1/ qi Assessor's <br /> / /V t l !�2 Parcel# <br /> WELL Location �� ��« � across City � Zip_ / <br /> PROPERTY Owner A►� Z1a6A6�] Address Pt1 G C jG?5Yn City Zip ���ri�Phone 5� ���� <br /> 0,6-rr I f l MAT Address 3233 �-z�- -e`fi("k` Cit �'� ,Zi is#5�t 1 hone# l/ ��6 7Z/� <br /> C-57 Contractor ���� � ��p y-\�/ p—� <br /> Consultant/Sub Contractorfie—�e Address &L- W1LylT ity v-t1LNs# Phone# qO-7 /�b <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> ,JEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 pESTRUCTION(choose type below) <br /> OIL BORING# _ / O OVER-BORE <br /> WELL# � 0 PRESSURE GROUT v <br /> 'Other: <br /> COMMENTS: 'G► -�- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n 1f <br /> MONITORING Q HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES B NO WELL CASING DIA: L- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes `*o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 150 j+f�OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> COMMENTS: MI i A L LAC, !� <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: "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work,for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE <br /> /FOR ALL REQUIRED INSPECTIONS. <br /> Signed xy(/!�W .��/� `� Title/Company <br /> Print Name W.' �II C F-(� Lam[ �i Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued ! w �D Area <br /> Grout Inspection By Date Final Inspection By MOM FMD <br /> Destruction Inspection By Date p <br /> COMMENTS/COND ONS: <br /> k�& 1/41 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# &REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 01 / 3&OgZ, <br /> 1/18/2000 <br />