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ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 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 Title, Chapter 9-1115.3 an�d the standards of San Joaquin County Public Health Services, Environmental Health Division <br /> -CA Assessor's <br /> � <br /> WELL Location Q 0 c''m ` ra_ )e�Cross Street '�CA —City- �ro_L_�_^Zip q��37 arcel# / <br /> � <br /> C� Address � �� t City { Zip S 1 PhoneTM �`J 'd <br /> PROPERTY OwnerL'_ _y (� I I /� L �! 'I <br /> t1 ts1Address :() roll `tlSU City SLIklAJZip_Lil# Phone <br /> C-57 Contractor V`� w <br /> Consultant!Sub Contracts s1��7, :Z� tQP,ddress �� � -- +Y��` <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> p SOIL BORING# 0 OVER-BORE <br /> ❑PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> DIA. OF BOREHOLE <br /> MONITORING OLLOW STEM E_ _ <br /> MULTIPLE CASINGS? 0 YES NO WELL CASING DW-1— <br /> 0 EXTRACTION aAIR NAMMERlDRIVEN CASING THICKNESS <br /> L7 TYPE OF CASING: STEEL PVV OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL J� - �e TREMIE TYPE TO BE USED: AUGERS `J10SE <br /> d <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 3fes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 NAND AUGER APPROX. BORING DEPTH �r <br /> BOLTED TRAFFIC 80X or a STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED'?- 06 (if YES, list specifications here): <br /> COMMENTS: <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: "!certify that in the performance of the work <br /> for which this permit is issued, i shall nct employ persons subject to WORKERS'COMPENSATION taws of California.11 Contractor's hiring or Sub- <br /> contracting signature certifies the following: "l 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 Catifarnia.' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> WRIGHT ENVIRONMENTAL. SERVICES, INC. 3 210 <br /> CORPORATION HEADQUARTERS <br /> BUS.LIC.NO.651501 �h <br /> 67 E.10TH ST. 833-0758 <br /> TRACY,CA 95376 90-103-1211 <br /> DATE r� ✓O �1I <br /> l PAY r <br /> TO THE - ifpl <br /> _ ORDER OF v Q <br /> } <br /> �i /c' DOLLARS �� � tI <br /> 1: <br /> BANK OF STOCKTON _ <br /> TRACY OFFJCE a <br /> TRACY,CA 95376 EI <br /> FOR - .et�i� <br /> 11'00 3 2 1011' 1: L 2 L LO L0 3 ?I: 2 L 6 20 5 111.0 1 <br /> 1 <br />