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W46L PERMIT APPLICATIOOORM 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 Permit to construct ancior install the work described. This application is made in cc <br /> melpnce with <br /> San Joaquin County Development Title.Chapter 9-1(95.3 and the Standards of San Joaquin County Public Health Services. Environmental Hea�Division. <br /> WELL Location 1-n Indrziyid A✓Q.\ �5�' s,e., � M,, nSt cJ Assessor's <br /> Cross street • city r O i'1 Zp �� 3 ��JParceY.0 25 -3 - 9 <br /> PROPERTY Owner NeS+ le'USA� no Address 8� (�,13rond 6(adCity cdc.l Zipg]ZO Phone# Ifr��✓c�`--rJ��(� <br /> C-57 Contractor t"REciSiip0 SkMQU Address 1`l0o Sr So 9. City d JN L'p'H%r`1Lief 6 b3 " Phpne#Sin 2'3A JS <br /> Consultant/Sub Contractor_.lT ee iLP Address�loa5' OJQT C•HtCA[.O City ce-*2.a¢.Otic# PhcneIi 9ZS ZW--&LU <br /> GIS Coordinates:X Y Township 2 -)owl kRange Incl.C+ Section_ <br /> WORK TO BE PERFORMED <br /> [NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HANG-AUGER.OTHER-) 9 OESTRUCTION(choose type below) <br /> JWSOIL BORING# 0 l�-'J l L - 0 OVER-BORE <br /> 'Other. Q WELL# _ Q PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM OIA.OF BOREHOLE 21' MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA:_ <br /> o EXTRACTION a AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC o OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERSPLEGHOSE <br /> a AIR SPARGE •BUSH POINT GROUT SEAL PUMPED: 9/yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> -&SOIL 30RING 0 HAND AUGER APPROX. BORING DEPTH 2`I�e-)-- Q 30L EO TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> COMMENTS: -A be Ovu G,t--)t-{r .�(Nn4l.J•nt7f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereoy certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. State Laws. a(gJWes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the`allowing: "I certify that in the performance of die <br /> &&kfor which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of Calffomia." Contractor's hiring d= <br /> contracting signature certifies the following: 'I certify that in the performance of the work forwhich this permit is issued,I shelf employ persons subject <br /> WORKE.4S'COMPENSATI N Caws o/California.' <br /> THE PPL ICA ST L 48 HRS IN ADVANCEFORALL REQUIRED INSPECTIO S. <br /> � Signed x -- - Title /1 eto 'e0l0 L/Date j/ �Z t/V C. 2 <br /> SEE SIIN UNIT IV WORK PLAN DATED —t7 <br /> DEPARTMENT USE ONLY <br /> Application Accepted 8y I rte__— Date IssuedOx% _Area <br /> Grout Inspection By-_�"-,,,,,,,a Date 21 0o Final Inspection By Date 2 D� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCCUNTING ONLY: AID# FAC# <br /> i <br /> PE CODES I FEE INFO AMOUNT REMITTED I CHECK#ICASH RECEIVED BY I DATE I PERMITISERVICE `REQUEST NUMBER INVOICE <br /> 1 ZS too I -20 C7-- <br /> C-57 <br /> -L 57 LICENSED CON-IRACTORIMUST SIGN LICENSE&WORKERS' COMPENSATION DECLURaTION <br /> UNIT IV-6/23/99/sign bkoo/MI <br />