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G ( � Z3 WEL?PERMIT'APPLICATION RRM, <br /> FILLW ■ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �D ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> O (209) 468-3450 <br /> ^, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <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 Co---iy Public Health Services, Environmental Health Division. <br /> 1002- Assessor 2)9 <br /> ssessors,9 <br /> WELL Location ACross Street CltYXk� rParcel# T?, <br /> PROPERTYOwne( "^�^l., Ce U+ ('- Address3 4�inca/n C.e.7kr City$f ktaj'1 Zip952o Phone#2o9-y7$- `/'Loc <br /> setas+opoI9.SY731J /F��8/phone#7o7-5/Z-3Z7 <br /> C-57ContrectorWeekSPr-iIIi9 Address�0.50ek I��a Cdy Zip <br /> i2 k Fme Y1V 11eV� ,1/ /} Phone# $/0-�2-ys0. <br /> Consultant)Sub ContractorLFR 1-eyrilC�Fr'ickP Address(�00 Bowe//Sf. City <br /> 13 <br /> WORK TWBE PERFORMED <br /> gNEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVERBORE <br /> SWELL# E t�-) () PRESSURE GROUT <br /> *Other: / _ <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS IZ.2S <br /> AMONrrORING 0 HOLLOW STEM DIA OF BOREHOLE ULTIPLE CASINGS7�IYES 0 NO WELL CASING DIA: <br /> O EXTRACTION HAMMERlDRNEN CASING THICKNESS 5019 0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR kMUD ROTARY DEPTH OF GROUT SEAL 0— 9O ' TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED:.AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH /Z O *BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED7 (if YES,list specifications here):12 STS/ O-9c <br /> COMMENTS: TT�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this application anw <br /> d that the ork 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 issued,I 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 workfor which this permit is issued,I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> THE APPLICn(AANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed �Z t , Title A'�.=._._Date_ <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY A <br /> Application Accepted By Date Issued �! D . Area <br /> Grout Inspection By <br /> Date Final Inspection ��_Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DA E PERMITISERVICE REQUEST NUMLINVOICE <br /> 0 MuJ £s'1 An <br /> UNIT IV-5/99/MI <br />