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,.r <br /> WELY PERMIT APPLICATION 06RM UNIT IV <br /> { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ECENED <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHQ) <br /> 344 E.Weber, Third Floor, Stockton, CA.,.9152,012 JUN 2 9 2000 <br /> (209)468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SER\ACES <br /> Application is hereby made to San Joaquin County f'ar a permit to construct andtor install the work described. This application is made in compliance with <br /> San Jisaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public health Services,Environmental sescors Health Division. <br /> llltELLLocation, lit } 5tt°ee,-f Grassslreet,At�oC City {` zip_ Parcel;_ <br /> PROPERTY C+wncr,��., <br /> .n 5�#-. t#s'I Address�#zFS N k Rof+s ity t0 Zip1S?A2 Phone# <br /> V UJ l�,n�a Address F't C +k 51 city aU»sra zip`1f LLIc#7za Phare#9u./ t` -- t+ c►. <br /> C47 Contractor <br /> r� c.I� A�drass, City. o��t,'esLicit Phone# ��'2'i �s:'L:t <br /> Consultant f SubContraCMr <br /> ' <br /> l <br /> .. ;Township �; �Ranged <br /> GIS Coordinates:X �. .. <br /> WORK- BE PERFORMED <br /> �+�OESTRI:ICTICIN(choose type below} <br /> r: .. <br /> 0 <br /> NEW WELL 1 BtiRiNG{CPT GEOPRCIBE.I�tYDRC�PUNCH;HAND-AUGER,OTHER*) /"�► AVER-BORE <br /> SOtL BORlBits*. :WRESSIJRE GROUT <br /> 'Other. <br /> COMMENTS' <br /> TYPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -----' MULTIPLE CASINGS?[�YES U Nd WELL CASING DIA.. <br /> Mt7NIT1�RELL HOI LOW STEM, 01A OF BOREHOLE_ <br /> A1R:.HAMIIAR/GIR11l~[+1 CASIN�� i EiICKNESs_�,_ �.TYPE,O C.�4Skl+tfia: STEEL Q.PYC .n i3rFIER; _ <br /> VAPOR t4{IJD R+DTARY <br /> C}EPTH OF GROUT SEAL_ _ TREMIE TYPE TO BE USED. 11AUGERS OHOSE <br /> 0 <br /> 13AIR SPARGE: p PUSH POINT GROUT SEAL PUMPED: p Yes n No (NOTE. MAXIM lM FREE-F�►1-L SE TH i5 3tF' <br /> a SOIL BORING Q HAND AUGER APPROX.BORING DEPTH----------LI BOLTED TRAFFIC 803t nr C15Tt}VE PIPE. <br /> a OTHER. �Q'OTHER <br /> cokdUMR CASING PROPOSED? {rf1f:ESlist speciications herM): <br /> COMMENTS; <br /> NOTE: OFF6ITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin Countythat n art r. tate <br /> at ante of the.work <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature Certifies the following:"I c�#tying or <br /> for which this permit is t3tsued it shalt not employ Persons subject to WORKERS'CQMPEhfSATtpOeN taws nt Ca[tforrlta" C rso s subjectnaub <br /> contracting signature cottiftS the following. I+certify that in the performance of tha work for which this unit is isst e !shalt ignrpWy Ae <br /> WORKERS,COMPENSA1761V taws of Cettfomis." <br /> CALL THE UNIT Ill INSPECTOR 48 WORKING HRS IN AOVI4NCE FOR ALL RECkt3lREL1'INSPECT[t?NS. <br /> 'Tdle1Company '1J0:5! lL. 3i r to r. <br /> Signal x <br /> Print ' Date <br /> to <br /> SEE SITE M P IN U�17 tit W�}RIK�FLANS CtATEC1:. � <br /> f DEPARTMENT USE ONLY <br /> t .bate Issued ea- —.�"_. <br /> Applicafth Accepted:Sy <br /> Grout Inspection SC18ite Date, — <br /> By Final Inspection By <br /> Do$truedolr Ipspechon By {,tZ W At-.c Dat <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY* A1�# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'{D BY ;DATE PERMIT!SERVICE RE{2lIE8fi x ChlVC71GE <br /> 1/1812000 <br />