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I <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECE 'WED <br /> ENVIRONMENTAL HEALTH DIVISION (" PHS -EHD" ) v <br /> 304 E. Weber, Third Floor, Stockton , CA ., 95202 NOV 2 $ 2000 <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> CITY of STOGKTON SIDEWALK Assessor's <br /> WELL Location l3 O N H O N T E R 5 TR E E T Cross Street E. W F " R AV. City STO GK TO N zip. 5 Parcel# <br /> PROPERTY Owner G17Y OF S"( OGKTO N Address 425 N . EL OORA00 _city STOGKTDN zip95202 Phone# 209 - 93} - 8366 <br /> �T YALLE�( C- S'} <br /> C-57 Contractor FtSGH ENV . Address � 99 SHEItI ' S P1 AGE citySpfk, 14 S Zip951S2Lic#6$ 38fiSPhone# 209 132 " I <br /> ikAWC �— <br /> Consultant / Sub Contractor RAIU Ft4I Address P . 0160)< 869 _city (AYRIETA Lic# 594 Phone# 91b - 354 - 32b0 <br /> GIS Coordinates: X <br /> y., Township Range. Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING ( CPT, c.FOPROBE_ HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 OVER-BORE <br /> SOIL BORING If Z <br /> 0 PRESSURE GROUT <br /> 0 WELL # <br /> 'Other: <br /> COMMENTS: TWO GE0PR013E 5D 14 (3oftINGS oN CITY SIDEWALK - ENGROACHME1Jt PERMI <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS A TT A C ED <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2^ IPI MULTIPLE CASINGS? 0 YES I NO WELL CASING DIA: NA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA <br /> F TYPE OREM EI TYPE O BE USESTEELOD:V 0 AUGERSPC U R $HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE II PUSH POINT GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE"FALL DEPTH IS 30) <br /> 0 SOIL BORING p HAND AUGER APPROX, BORING DEPTH 3 S - pT• 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> l OTHER: GE DP R D f3E CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br /> COMMENTS: atopE OF W011h DRINILED IN IIAMAGE K11If1o11MEN1AL15 WORK PiAB , <br /> RTE D � 1 0 0 <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS ! <br /> certify that in the performance of the work <br /> will be done in accordance wit <br /> 1 hereby cenify that I have prepared this application and that the work h San Joaquin County Ordinances, State Laws, and Rules <br /> S and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 'I <br /> for which this permit is issued, f shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify 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 x <br /> Title 471 r / t _Date ll ' zi` ` Oy <br /> SEE SITE MAP IN UNIT IV WORK PLAN . DATED *1114100 <br /> DEPARTMENT USE ONLY ! _ ; ! y ' G O e.1 c� Y 2 <br /> Dale Issued DL Area <br /> Application Accepted Byl Dale <br /> Date l Final Inspection By <br /> Grout Inspection By � <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS Eftcrccl ( � rr� P <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3SD i � ► /5 <br /> UNIT IV - 6/1/99 /sign bkpg/MI <br />