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WFI& PERMIT APPLICATIONSORM 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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a peri[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 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> c TN Assessor's 11 i f I N T <br /> WELL Location i t�Q u ST�\AL- #%V C— Cross Street,IN iac 4- SL ity R\"PO 111 Zip 953(eL Parcel# <br /> PROPERTY Owner a IT'( DF- t2-\Po rJ Address Z59 IV WI6161, r\✓Q, City11 , POA) zp�l'S34: Phone# ( q 51`-Z)0$ <br /> C-57 Contractor PCZ-�-Akys0i SFt k`(Q t la,Address 1 oo Som S'� City j%&u nep Zip Lic cil.39-1,Phone# 510 14 lkcjlc <br /> Consultant/Sub Contractor rr Cod- ZAT1oQ Addres;41, cg&'P41iCthulc CitLCSLT , L UcX Phone#(nj5 ,0 <br /> GIS Coordinates:X Y Township 2 SOLyf k Range D EGSt Section 2-9 <br /> WORK TO BE PERFORMED <br /> y[NEW WELL/BORING(CPT. GEOPROBE. HYDROPUNCH.HAND-AUGER,OTHER-) A DESTRUCTION(choose type below) <br /> �PSOIL BORING# 016 --A- I OZ.--A 0 OVER-BORE <br /> 'Other: Q WELL# U PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE a-ti MULTIPLE CASINGS?Q YES Q NO WELL CASING OIA:_ <br /> Q EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> `VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE i!PE TO BE USED: Q AUGERS fil?BHOSE <br /> /A AIR SPARGE *PUSH POINT GROUT SEAL PUMPED:_ Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING o HAND AUGER APPROX. BORING DEPTH 24 Feet t a BOLI c0 TRAFFIC SOX or Q STOVE PIPE <br /> Q OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES.fist specifications here): 1 <br /> COMMENTS ThPSe tye- boyiaGSvi-I I (L✓Iv)141 lbe Wua `V r 5'Gt✓t/11�1 1 <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 fallowing: "I cert fy that in the perfomrance of Monk <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring owyy <br /> contracting signature certifies the following: -I certffy that in the performance of the work Sir which this permit is issued. I shall employ persons subject <br /> WORKERS'COMPENSATION Laws of California.' <br /> THE APPLI d STC LL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPEC-nONS. <br /> I. Signed z J Titlei-ni eo O '-S Date iy Cz <br /> SEE SI IN UNIT IV WORK PLAN DATED .p <br /> DEPARTMENT USE ONLY m <br /> / <br /> .application Accepted By. a� Date Issued I t I!� IOC Area <br /> Grout Inspection By Date I1 Z Final Inspection By (;r\'U� Date21 OG <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# rAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> deo( I .00 I aol� I �" 131S R# ao a`L 5'33 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLA-RATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />