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y—LG ItJ�& 5:2bAr•1 FRUtt P. 2 <br /> i' WELL PERMIT APPLICATION FORM UNIT 1V <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES <br /> ENVIRONMENTAL- HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 55242 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPtRES 1 YEAR FROM DATE ISSUED <br /> ADD1iCatiOn is hereby made to San Joaquin County for a permit to construct 9ndJar Install the work descnT�d_ This application is made in corr:pliance with <br /> San Joaquin County OeveloQment Titter ha ark i 15.3 and the Standards of San Joaquin County Public Health Services.Environmental Ha31th Division_ <br /> I q SAssessors <br /> WcLLtoestiart v, . Cross Street �lcw ^t City SicckTeN zip aSZaC Parcai# —�� <br /> PROPERTY Owner CCLEEt��• 3�•* i; i i�5 Address ��1 N..S -r��.. sk . City sTor.Krc v �p4szcC Ptlane# <br /> C-57 Coe stractar Eso blv,f. Address 3,1,1 51 -(T 5 -� Ciry r"� -< Z;ps1SL57 LiC#{/�SrSI i Phon �� 7]Z-�Sx <br /> Consult <br /> ant 1 Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X YTownship Range Sectforl <br /> i <br /> C I <br /> WORK TO BE PERFORMED <br /> 9 �i r DESTRUCTION(choose type below) <br /> EW WILL 1 BORING - �GP�C�ZlHYDROPUNCH.>•iAND-AUGER OTHEW) {�G _ S E]OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> -Other:.) <br /> C^.MMENTS: <br /> TYPE OF VVELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW ST--M D1A.OF BOREHOLE 1ILn MULTIPLE CASINGS?o YES p NO WELL CASING DIA: *•: <br /> EXTRACTION (]AIR HAMMERfORIVEN CASING THICKNESS NTYPE OF CASING: EI STEEL EI PVC 1�OTHER- <br /> Q VAPOR a M D ROTARY DEPTr1 OF GROUT SEAL��'7 TREMIE Type TO BE USED: p AUGERS DHOSE <br /> {] s IR SPARGE SH POINT GROUT SEAL PUMPED- Q Yes i�& (NOTA: MAXIMUM FREE-FALL DEPTH IS:30') ` <br /> U SOIL BORING HAND AUGER APPROX.BORING DEPTH Q 60LTED TRAFFIC BOX or aSTOVE PIPE <br /> CONE)UCTOR CASING PROPO5Ep-? /Ls�-,i if YES,fist specificatior+s Hare): <br /> COMMENTS; <br /> NOTE: OFFSITE BORINGSREQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> 1 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 fleensed agenrs signature certifies the following:I/certify that in the parformance of the work <br /> for whlch this permit is issued,I shall not employ persons subject to WORKMAN'S COMFI NSAF70N Laws of Callfomia." Contractor's hiring or sub- <br /> contracting signature certifies the following:'i cerW that in the perfarrr)anoe of the work lar wiriclt this permit iS;SSV@d,1 shall employ Persons subject to I <br /> WORKMAN'S C0MPF-NSA710N Laws of C0610mie.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x '' I r� {�� 'Ni/+lZr!TEC TitleData <br /> I <br /> SEE SITE MAP 1 KI UNIT IV WORK PLAN -DATED <br /> f EPA ENT USE ONLY q l Z Area 3f O I <br /> Application Accepted By . L l Date Issued <br /> Grout tnspeaion By Rate Final Insp6aion BY Oate <br /> Oestructton Inspection ey Date <br /> COmmiiE 5 I CONDITIONS: <br /> FACA <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK#1CAShl RECEf EO BY DATE Pt"RNIITISERViCE REQUEST NUMBER INVOICE <br /> `� 1 00 g g 4 <br />