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_ I <br /> 011,rELL PERMIT APPLICATION FORM 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 /> 1209) 468-3449 <br /> NON-REFUNDABLE PBRMIT EXPIRES 1 YEAR FROM oATE :U ED <br /> Application is heraby made to San Joaquin County for a permit to construct andlor install tt+e work de&scribed. This application is made in coniiliance with <br /> San Joaquin County Development Title. Chapter 9-1115.3 and the Standards of <br /> San'Jofaquin County Public Healthse�g environ <br /> a mental <br /> ealth Diviscon. <br /> 0 <br /> Cross Strzetr51�[ltwf ity Zip <br /> WELL Location IJt4f � ` <br /> Address City,(10 - Zip +;j LPhone# <br /> PROPERTY Owner -�11e3 �- 916-373-�1i� <br /> T��j Jn� <br /> ff U1M ( PhoneT_ <br /> C-57 Contractor t �p{t ddresSRO.'sa�C i�'b nCiry -�Zp <br /> Consultant!Sub Contractor A <br /> Addre55J�(r�w�orn,n P.�k1?i. Ity <br /> Y <br /> Township Range. Section <br /> GIS Coordinates:X <br /> WORK Tin BE pERFORMEfl below) <br /> FiYDRQPUNCH, HAND-AUGER, 47NER'} � 7ESTftUCTION(choose type <br /> �j NEW WELL!BORING(CPT.GEOPROBE. ©OVER-SORE <br /> OiL BORING# ;S4-RESSURIE GROUT <br /> 'Other; <br /> COMMENTS: <br /> jYPE �L fNSTALLATION (YPE CONSTRUCTION SPECI> ]CATtuLT1PLE CASK IGS?0 YES II NO 1!`lEtt CASING ©IA: <br /> HOLLOW STSM DIA. OF BOREHOLE-_ <br /> []NtQNIYOP.ING � � TYPE OF CASING' g STEEL Q PVC it OTHER;-�—_...-- <br /> (j EXTRACTION [�AIR HAMMERIORIVEN CASING THICKNESS, REMIE TYPE TO Bt=USED: ❑AUGERS QHOS= <br /> j] MUD ROTARY DEPTH OF GROUT SCAL <br /> 7 F CASI <br /> �]VAPOR GROUT SEAL PUMPED: Byes � No (NOTA: MAXIMUMFREE-FALL DEPTHIS 30' <br /> Q AIR SPARGE PUSH POINT Q BOLTED TRAFFIC BOX or 4 STOVE PIPE <br /> AUGER APPROX. BORING DEPTH <br /> U 501E BORING Q HAND ACONDUCTOR CASING PROPOSED?— <br /> (if YES, list specifications here); <br /> Q OTHER, O7HER <br /> COMMENTS: <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESSOR ENCROACHMENT ROACHM ty NTd'PERMITS__nances,State and_ , <br /> I hereby certify that I have prepared this aQptication and that the following't's signature certifies tilig ,. <br /> and Regulations of the San Joaquin Cal!not employ persons subjecttonWORK>=RS COMP,5t4SAnoN Laws of California.fy that In"Contracto s hiring <br /> ve performance �su or <br /> for which this permit fs issued,1 sh <br /> persons subjeCt!a <br /> contracting signature certifies the following: "f certify that in the performanceVIOof the Mork forwhich this permit is issued, !shelf emp ay <br /> .;<C S'COMP NS�TION taws of Gafifornia." <br /> C LLT E U IT Iv INSPECTOR 48 WORKING HRS IN ADVANCE AOR ALL REQUIRED INSPECTIONS. <br /> Tli)elCompany S 7'9A f°-f <br /> Signed <br /> x <br /> Print Name <br /> :.UiV1T IVQIK LA <br /> SE�::._Sl"fE..,MAP:w:iIV <br /> " :• L. DEPARTMENT USE ONLY <br /> td <br /> I Date Issued <br /> DD Area._. <br /> Appkation Accepted By 4Date ! tnal Inspection By Date1- <br /> Grout Inspection By' Date <br /> Destruction inspection By <br /> GO[UiMENTS 1 CONi]ITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE 11,450 AMOUNT RENtl7TED Gi-IECK-0Flt=G'D 8Y' DATE PERMIT f SERV1Clr FtEflLlE57# INVOIDE <br /> OZ� 'd � ho aD OOzZId�b >.izs/zoao <br /> SO 39v,c J007A HIAIJ EEbE89b6i�Z 80 trL 900Z1ZZItr� <br />