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WELL PERMIT APPLICATION FORIVI UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER] IE III <br /> ENVIRONMENTAL HEALTH DIVISION (" PHS -EHD" ) <br /> 304 E . Weber, Third Floor, Stockton , CA . , 95202 NOV 2 $ Z000 <br /> (209) 468 -3450 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Developpment Title, Cha ter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> COVNY7 PARktN �i CrARAGE Assessor's <br /> WELL Location ! 30 N . L�UI�ITER 5TRFET Cross Street <br /> wc6ER AVCity STOGkTO$t zip 95202 Parcel# <br /> SAN T0A 6IN �At, TT <br /> PROPERTY Owner PA61L 11 1E5 MGMT . DEP7. Addressl312 E . SCOTT5 AVL City STOGkTDN zip 95� Phone# 209' 468 - 335} <br /> VALLEY <br /> C-57 Contractor FlSCH ENV, Address 399S !{ ERI ' S pLRCp Cily5PRtfI Ziippj5152Lic# Rg ;E65Phone# 209372 3534 <br /> RAII <br /> Consultant / Sub Contractor ITA M A GE ENV , Address P, O , BOA 969 city j R ZETA Lic# S8 S 6 Phone# 916 ' 354 -3250 <br /> GIS Coordinates: X <br /> y , Township Range Section <br /> WORK TO BE PERFORMED _ <br /> NEW WELL / BORING ( CPT, GEOPROBE. HYDROPUNCH, HAND-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> ING # ! OVER-BORE <br /> I SOIL BORWELL # PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> ll MONITORING Q HOLLOW STEM DIA. OF BOREHOLE 2- 1N MULTIPLE CASINGS? 0 YES IND <br /> WELL CASING DIA: NA <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: a STEEL PVC OTHER: N A <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3 s - F r TREMIE TYPE TO BE USED: AUGERS CHOSE <br /> 0 AIR SPARGE f PUSH POINT GROUT SEAL PUMPED: a Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> � SOIL BORING a HAND AUGER APPROX. BORING DEPTH 3 S ' F T <br /> BOLTED TRAFFIC BOX or O STOVE PIPE <br /> OTHER: GOE F R 0 g E CONDUCTOR CASING PROPOSED? N O ( if YES, list specifications here): <br /> COMMENTS: SCOPE of woRK QETRILEO iN RAMAGE [ NV ( RON � NYALIS Wo {zK PLAN <br /> DRTED l 00 <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: "I certllC that in the performance of rhe work <br /> for which this permit Is issued, I shall not employ persons suh%ecf to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring to sub- <br /> contracting signature certifies the following: 'I certi/y that in rhe performance o/ the worn fcr wh•'ch Lhis pernet is ensued, I shell employ persons subiecl to <br /> WORKMAN'S COMPENSATION Laws of California. " <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS . <br /> _ Title �l1JNPJ2 Date <br /> Signed x P /lt�G— <br /> SEE SITE MAP IN UNIT IV WORK PLAN . DATED II `t I Do <br /> DEPARTMENT USE ONLY Area <br /> Application Accepted Byj[p q Date Issued (� — fo _ CIS <br /> AAM X Date Z 2 Q Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By — Dale <br /> COMMENTS / CONDITIONS : pry $ o <br /> hilia � — G <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC (CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 35u1 Try - t 8 <br /> 1113 ca IllilhI C 0 4# dm Lf � <br /> UNIT IV - 6/1/99 /sign bkpg/MI <br />