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WP:f-L PERMIT APPLICATIOr l FORM ,--,w-. -l"LINIT IV <br /> SAN JOUIN COUNTY PUBLIC HEALTH SERVICES j <br />, <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> i <br /> NON-REFUNDABLE PERMITEXPIRES 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 Thle,Chapter 31115.3 and the Standards of San Joaquin County Public Health Services-Environmental Health Division. <br /> / � ! r� G $} Assessor's <br /> WELL Location_-r) in 0 E , rr1Y/n Cel 4- 5'{', Cross Street. c ,- 1 City STOC K7 rn Zip 95LnS Parcew <br /> PROPERTYOwner &I6.:r 6rewfl Address L//Qu 1, , f/Pmr-.�-1' City �l <br /> S7CLxlZipgl.S24.277Phonee Z'9' (/ I63 -eSZ", <br /> -57 Contract' A , G . £. - Address 7 CC 5 IV,/l.�t:i 1Sr.n� shy 57o(17",ZPp j L 57" 1—,.c PhoneC ZCS- GHJ-JCC' <br /> onsuft n/Sub Contractor A ,G -E . Address7 GCS IV 4 15Mw 7 city 57a/!r^UG (p$�jZ7 Pnone, Zai Y(d7-ioo Y <br /> GIS Coordinates:X , Y ,Township Range Section 'I <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT. GEOPROBE. HYDROPUNCH. HAND-AUGER,OTHE '). 6 JZ/I4 S 0 DESTRUCTION (choose type below) <br /> >'SOIL BORING- P-In P-7 P P-1 a Q OVER-BORE <br /> r0'WELL# Mw 1 ,v.,_+2 ui tn&+L,) 2411 c,o r2/z/o-D . aPRESSURE GROUT <br /> 'Other: <br /> COMMENTS: - <br /> TYPE OF WELL CONSTRUCTION ION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z'/ MULTIPLE CASINGS?0 YES a NO WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 ST'cEL 0 PVC 0 OTHER: . <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL "",Lsr9 TREMIE TYPE 70 BE USED: p AUGERS NOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes xNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH `jg' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ( <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? H YES. list specifications here): <br /> i <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereoy certify that I have prepared this application and trial 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 cenrifies the'followinq: "I certify 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 California." Contractor's hiring or suo- <br /> contracting signature certifies the following: -1 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> /THE APPLICANT/MUST CALL 48 HRS INADVAN E FOR ALL <br /> /'REQUIRED INSPECTIONS. e <br /> Signed x /r 1 i Tdle/f5 , T L?V 0215-7 Date 196 - Z�- 7 5 I <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DA D -�- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Le Date Issued Area U 7 I <br /> Grout Inspection ByDateZr/0 o"'Z1Z1op Final Inspection <br /> \By. Date <br /> Destruction Inspection By ta� Date <br /> COMMENTS 1 CONDITIONS: - <br /> i <br /> ACCOUNTING ONLY: AID- <br /> FAC-- <br /> PE <br /> AC-PE CODES FEE INFO AMOUNT REMITTED I /CASH RECEIVED BY DATE ( PERMIT/SERVICE REQUEST NUMBER I INVOICE <br /> 3yZJ/ I S-c7 3 I Co . b�2i( # 7% <br /> C-57 CON-TRACTOR SIGNATURE REQUIRED ON'BACK <br /> Ute IV-6/18/99/sign bkpg/MI <br /> f <br />