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2- 10-2000 11 : 24AM FROM P. 1 <br /> I - <br /> j WELL PERMIT APPLICATION FORM 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 -3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication 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 /> an Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. ' <br /> Mt� 111. � a rAddress � ` i Wr IA Cit Y�/� •-` � Zi P Lic# <br /> Assasso <br /> r�'S <br /> [ELLLocationsi Slp"11L) AVUDCrossStreet i✓ Cit r) Zip swvr Parcel#� <br /> E/ Ud BaS Address �On n0. S _ Phalle# <br /> 9 <br /> ( - 3 ;ROPERTY Ownerity Zip <br /> _57 Contractor Phone# q00-3Q3 <br /> dell G/n � I , Fn//✓ '1 II //11 nn,, <br /> C ler Gro x eW h V n I r IV f iGf Phon D 3d� -Q ,� <br /> :onsultant ( Sub Contractor 'eO+�W L Address 9 IecJv�Ry "36 <br /> ex <br /> ;IS Coordinates: X., Y., Township Range Section <br /> VORK TO BE PERFORMED <br /> ANEW WELL I BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') p DESTRUCTION (Choose type below) <br /> )0 SOIL(WELL #BORINGI) P - w S - 00VEBORE <br /> 0 PRESSURE GROUT <br /> Other: <br /> �OMMEN i S: 1 <br /> D,wl -P aim extra a1 �/ =9� ' tMlrchoti s•lIU•�J�Px71IL+GrI'vn <br /> TYPE OF WELL 6fl tl L INSTALLATION TYPE w CONSTRUCTION SPECIFICATIONS <br /> 7 MONITORING 1�HOLLOW STEM DIA, OF BOREHOLE 10 `n • f tnMULTIPLE CASINGS? BYES *NO WELL CASING DIA #L <br /> (EXTRACTIO BAIR HAMMERIORIVEN CASING THICKNESS 3-W4 CTIYPIE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> IVAPOR �_� 0 MUD ROTARY DEPTH OF GROUT SEAL Seg CtffaCW TREMIE TYPE TO BE USED: 0 AUGERS EHOSE <br /> XAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> J SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH 30 ft /16t•,T' a X BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: ,v p OTHER CONDUCTOR CASING PROPOSED7 _ ( If YES, list specifications here): <br /> COMMENTS= <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT 40 <br /> ( hereby certify that I have prepared this application and that the work wit[ be done in accordance with San Joaquin County Ordinances, ate ks, and Rules <br /> and Regulations of the San Joaquin County, Homeowner or licensed agent's signature certifies the following: "I certify that m the a of the work <br /> for which this permit iz issued, 1 shall not employ persons subject to WORKERS' COMPENSATION Laws of Califomfa" Co a do hiring or sub- <br /> . contracting signature certifies the following: 11 certify that in the pertormance of the work for which this permit is issued. I shall employ ons Subject to <br /> WORKERS' COMPENSATION Laws of Califomia, " <br /> CALL THEUNIT' IV INSPECTOR 48 WORKING HRS IN ADhW C(E .FOR;ALL REQUIRED INSPE/CTIIO� NS. <br /> Signed A ' 7"2(�) � Tdle/Company Yr�W-a 4Lie.n• kst - Clectrwa7 rl 2 V <br /> Print Name 1Y WQ.rrl / ` NZltyi+tctrt Date <br /> 812E WTE RAN IJr I 11? _R[f <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� !! Date Issued B Area <br /> Grout Inspection By. ` Date b "Lu /JZ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS; <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3SC SPJ , 00 <br />