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IV <br /> WELL PPI�RMIT APPLICATION FOjA UNIT <br /> . SAN JOA6IUIN COUNTY LI1SERVICES <br /> ENVIRONMENTAL HATHI31VIS0N (PHSEHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDA LE RSUL E PI S 1 Y FROM AT ED <br /> Application Is here-by made to San Joaquin County for a permit to construct andlor install the work described. This application Is made in compliance with San <br /> Joaquin County Development Mile- <br /> Chapter <br /> 9-1115.3 and.the Standards of San Joaquin County Public Health Services.Environmental Division. <br /> WELL Location r ri^ir�l w k cross <br /> /Surer/� ,n. �iry ���Zlp Parcel# <br /> ,�2al��O>< 7✓�/ / // �f �/1/ Zip,!"Phone#�9 <br /> PROPERTY Owner Address <br /> �NPRvf3 �i ne#a <br /> C•57 C tractor �iWdress ✓ /��� g D, <br /> 66�!'y'! City�'Y1 Phon <br /> Consul nt I Sub Contractor Address / <br /> Range <br /> Y ,Township_ <br /> � � Section <br /> GIS Coo inates:X <br /> WOR TO E PERFORMED: <br /> 0 DESTRUCTION(choose type below) <br /> B NEW WE /BORING(CPT <br /> PROBE,HYDROPtINC •HAND-A G R,OTHER-) a OVER-BORE <br /> BORING# B PRESSURE GROUT <br /> WELL# <br /> *Other:: <br /> COMMENTS: <br /> TYPE OF WELL STALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA <br /> 0 MONITORING (] TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> a EXTRACTION 0 AIR MERJDRIVEN CASING THICKNESS— 7REMIE TYPE TO BE USED: 0 AUGERS ONOSE <br /> 0 VAPOR a MUD R RY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE a PUSH POI GROUT SEAL PUMPED: 13 Yes 0 No (NOTE: MAXIMUM <br /> SID UMTRAFFREE-FALL <br /> BOX mor 0 STOV 15 301 <br /> p SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH o 13 YES. E spec fiFIC Bs here):��� <br /> 0 OTHER: 0 OTHER ONDUCTOR CASING PROPOSED. <br /> 71.1 _110 <br /> COMMENTS: LG D <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 eceordanoe wit L and Rules <br /> tnances,State <br /> h San Joaquin <br /> oaf inl the pen`ormance of Me work <br /> and Regulations of the San Joaquin County- Homeowner or Licensed agent's signature cOMPEertlfles the following: arsons subject sub- <br /> for <br /> which this permit Is issued,I shall not employ persons subject to WORKERS'COMPENSATION laws of California" Contractor's hiring or <br /> to <br /> contracting signature certifies the following:"1 cer67y that in the performance of the work for which this permit is issued.1311311 employ p <br /> WORKERS'COMPENSATION Laws of Calilomia.' <br /> * T UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE R ALL REQUIRED JN � ION <br /> Title/Company / vim•¢ <br /> Signe <br /> Date O <br /> Print Name <br /> SITE FILE ADDRESS/WORK PLAN DATE: <br /> D PARTM N USE Y Area <br /> Data Issued^ o <br /> Application Accepted By Datel— <br /> Final Inspection By Oates_ <br /> Groutlnspection By Date <br /> Desbuction Inspection By <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PG CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERM Tf 13ERViCE REQUEST# INVOICE <br /> 3SvI 8'y — 8 � as 7 6/Jy/UU roe 3i� <br /> G-57 exp,WC/Waiver— C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />