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08/0812001 16 05 2094683433 T FIFTH FLOOR PAGE 02 T <br /> - _ VAI PERMIT APPLICATION FORM UNIT IV <br /> �uG -7 SAfl2JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> CO�� (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApDlrc3t5on is hereby made to San Joacturn County for a pemvt to construct and/or tnsral]the worn descrbed This application is made m compliance with <br /> San Joaquin County Deveiopment Tide Chapter 9-1115 3 and the Standards of San Joaquin County Public Hsatth Services,Environmental Health CTvrsron <br /> 4 l "Y- Assessor's <br /> WELL Locadon 1100 MBrttU'�� �vU�'� Cross Street it40A ''Qv LCrty <br /> PROPERTY Owner TK FjeayJ4azxAe% Mtm^ddress &2 'Shin R,4- Crty SIocK. Zip.9 521 Phone <br /> l�I �1lAY lirw b ZEp 4"gSr 3 LrtC�U65 P honor 425)3l3-Sftr, <br /> C-57 Contractor-aLs�►� �t Address 9Sn�{Ou+2'��__ _ Crhl <br /> Gan,ultant i Sub Contractor C2►r+tilo�.ir �yiwr V �ACdreSs 2Z0 parte rriS_ tCity eSa•�aW{G� t rc# PNonn#C1 f)915-4bso <br /> GIS Caord+nates X Y Township Flange Secuon <br /> WORK TO BE PERFORMED <br /> VIEW WELL/BORING(CPT GEOPRO6E HYDROPLINCFI HAND-AUGER OTHER-) n DESTRUCTION(choose type below) <br /> VY901L BORING s 5B-1 end SE-Z a OVER BORE <br /> 0 VVELL It a PRESSURE GROUT <br /> -other <br /> C—CMMENTS <br /> TYPE OF WELL CONSTRf1CTION TYPE CONSTRUC17ON SPECIFICATiONS <br /> apNITORING a HOLLOW STEM Wk.OF EOREHOLE�_MULTIPLE CASINGS;a YES 0 NO WELL CASING DIA <br /> TRACT10N a AIR HAMMER/DRIVEN CASING THICKNESS r-,(A TYPE OF CASING p STEEL a PVC a OTHER <br /> fa VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED a AIJGERS OHOSE <br /> a?SIR SPARGE t.�USH POINT GROUT SEAL PUMPED a res p No (NOTE, MAXIMUM FREE-FALL DEPTH IS 30') <br /> Gg;OIL BORING 0 HAND AUGER APPROX BORING DEPTH 60 p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 3 OTHER CON UUCTOR CASING PROPOSED? (If YES bst specx5cauons hers) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS'REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby corofy that i have prepared this appticatnon and usat Vie work wilt Ge done,n accardance„nth San Joaquin County Ord,nance5 State Laws and Rales <br /> and Reguiatons of the San Joaquin County Homeowner or ircertsed agents signature cerlifies the following It comfy that rn the performance of the work <br /> for whrch this permit is issued,1 Shall nor employ persons sub/ecr to WORKMAN S COMPENSATION Laws of California." Contractor's htnrig or sub- <br /> contracting signature certifies the following 'I certify that rn the pedormama of the work/or whrch this permit is issued I shall empfay persaaS Subject tv <br /> wORKMAMS COMPENSA T70N Caws of California - <br /> THIr APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Title —?yq 1.e.0 + esll, Date 3 — D 1 <br /> Srgnad x \ . <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 31 O t <br /> , II ff�� /J DEPARTMENT USE ONLY �j <br /> ADDI=t,on Accepted By l k"—C � _ _ —Date Issued Area O✓- o <br /> Grout tnspect,on By Date Final Inspecbvtt(BWDate <br /> Oeotruc fon Inspection By Date <br /> COMMENTS I CONDMIONS <br /> FAC: <br /> COUNTING ONLY AIDS <br /> PE CODES FEE INFO AMOUNT REMITTED C14ECKNJCASH RECEIVED BY DATE PERLIMSEFMCE REOUEST NUMBER INVOICE <br /> 3,S( <br /> 0 /3z <br />