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VVELPPERMIT APPLICATION FORM UNIT IV <br /> t;,cr <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESC!I,iCU�fr=-'h} <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD' 5 U <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UES; <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED }'ERHT/SCnR�#f:=` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made uY&dmpliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division, <br /> 1112ZI��r� f - ' <br /> WELAS52550fS p <br /> L Location-`3 f�j lti'.. HAi �1 a.A r'�vt . Cross Street Sc.c 6+ Si City STT tC fn,. zipljj�Z'=�( Parcel;# <br /> PROPERTY Owner sii f!•>'� <br /> tAZ: I O:� CitySQCro ZiP252± Phonesj2-, i) quj - ,,> <br /> C-57 Contractor '^ .1C'sL uAi�l. Coll <br /> eb.SCfaDE eJ^I Address City '.irv`rt?� ZipCis?`?'ZLic,'F7f7Sf-'Phonetb) Ci35 <br /> Consultant/Sub Contractor Address S:i7 Sfjf3wiIJ - City-!LTL,(t>, Lic#J _.ZZ. Phone#\z-k Y6 •J:, <br /> GIS Coordinates:X , Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) <br /> 0 SOIL BORING SES('RUCTION (choose type below) <br /> kn�' EI L' OVER-BORE <br /> COMMENTS � = n `C NhiS5 i.;EJts '/r 4 BPRESURE�,GRyouT <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> -MONITORING I HOLLOW STEM DIA.OF BOREHOLE 5VV MULTIPLE CASINGS?0 YES XNC '•NELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES;Fc �� TYPE OF CASING: 0 STEEL )(PVC <br /> 0 OTHER: - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL enk A. °Sl v TREMIE TYPE TO BE USED: XAUGERS 0HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH (s> ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? &r),'I (if YES, list specifications here): <br /> COMMENTS: [I€(e:�jptip�'ilicl-,5�') fY1C1•'IiT� ^ nC vV { fie +W6y - t .'� h:/� tirr�t �` <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: "l certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contracmi-s hiring or sub- <br /> contracting signature certifies the following: "I cern✓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 IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed J::rir4,Y' `f� l'a. vt:L .ry., ( _ / <br /> / ` - Title i%�,c/y t-+' *-�: 1..y.�e t Date <br /> SEE SITE lM'4 IN UNIT IV WORK PLAN. DATED 12117,1(07 <br /> n DEPARTMENT USE ONCE / ' <br /> Application Accepted B f'�/ uj n <br /> y Date Issued ! Area7 <br /> Grout Inspection ByLr`Y'I Date/ I. V Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: �/�fy.,,1` <br /> - ( a�G/vlvtLfI Sr s e�C ilea-21 cr -Er Az <br /> ACCOUNTING ONLY: I AI04 I -AC$ <br /> PE CODES FEE INFOAMOUNT REMITTED CHECK/CASH RECEIVED BY j DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> �I 2C%J> - � (�n� � L,��' � _��-.S-s� � �� � rvf_,I��SR# �Sfj�,��'1 •'-�' <br /> G5' Lt NSED CO',i. ' C7C)IR �%LST SIC-N __-Ei SE P, -yrr 4p E S' COMPENS_�T ON DECi kKkTIC?N <br />