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WELSP. AMIT APPLICATION I %",.. UNIT IV <br /> s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> V <br /> N� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 btu <br /> (209)' 468-3449 1" r 'C yy7Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -10 <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 /> Location D 9 f Eop7 A)f SJ Cross Street 0" Ci S7a Gk Zi Assesso <br /> WELLr's <br /> ry 5 0o p�i��/ Parcel# /{2 . 26 <br /> PROPERTY,Owner N-Gt <br /> Tom// /lrC..��L/Z�{/ 2"7 <br /> Address 1- City C�- Zipl.�"'�I/Phone# 2 P7e7 <br /> C-57 Contraclorli (�� AdtlressCityS� ^`aZip�,�Lic# -S�P26Phone# L�l �� <br /> Consultant Address ©046 2811-/7 city F"01-y-(AMIL-- 15TPhone# S71) SaS-'d;' Z"- <br /> GIS Coordinates:X I -78.5' F 7.S,Y 1/F1 15 0'D , Township / N Range 7y Section <br /> WORK TO BE PERFORMED _ <br /> �� ��_�� V+y"tslek'1lb- 777 -fir Ue <br /> `R'NEW WELL f BORING(CPT.GEOPROBE. HYDROPUNCH• HAND-AUGER.OTHER-) cy I � 0 DESTRUCTION(choose type below) <br /> Q SOIL BORING# a OVER-BORE <br /> 'Other: SWELL# 3 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> %MONITORING gHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES �N0 WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS Std 4/J TYPE OF CASING. Q STEEL )(PVC 0 OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 'REMIE TYPE TO BE USED: 0 AUGERS QHOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 715- 30OLTED TRAFFIC BOX or Q STOVE PIPE <br /> ()OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES. iist specifications here): <br /> COMMENTS: <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 certify that in the performance of the work <br /> for which this permit is issuad, I shall not employ persons subject to WORKERS'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 /> WORKERS'COMPENSATION laws of California." <br /> TH A LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ate 2" <br /> Signed x Title -2 Z 2 <br /> SEE ITE MAP IN UNIT IV WORK LAN DATED- <br /> DEPARTMENT US Y <br /> Application Accepted By Date Issued -7 a Area FJ 7S10 <br /> Grout Inspection By �Ji� + Date /1 Z Final Inspection By Date <br /> Destruction Inspection By 1J— Date <br /> COMMENTS IONDITIONS: Swum bloc-l- MW s i6a. 4o ri Ue �o�g L-eQ a--I— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC EQUEST(CASH RECEIVED BY DATE PERMIT/SERVICE RNUMBER INVOICE <br /> 3-p I b"7 7/Lrl' 00.4 3-17-/ <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JNIT IV- 6/23/99/sign bkpg/MI <br />