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WELL PERMIT APPLICATION tr6RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVE 0 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 16 1999 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> WELLLocationI1841c, N. Nwy 9`t 0-if"T"IVC CL-4RKSDA Assessor's O <br /> rose Street City LORI Zip Parcel#Or7— '10-51 <br /> PROPERTY OwnerWgoD?Al DCF- P�^rORSAddress639 f- "tIC4C04A Cr City j-OD I Zip4,' x940 phone#333-1116 <br /> C-57 Contractor SPEC-TR UNI Addressz31;�J VVI$W" D�4• City-5- C(CTbrVZipgs:taLic#yf22WPhone# <br /> Consultant/Sub Contractor64vbUr"D Zt,r2C Addresst711F KRI^I s`T, CityXTCab,VLie#r023 Phone# 83$-28eT <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> \NEW WELL/BORING(CPT,SEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 2C40IL BORING# OVER-BORE <br /> p WELL# 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> )11�4011­BORING p HAND AUGER APPROX. BORING DEPTH L'IS 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list 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 issued,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'COMP ATION Laws of Iifomia." <br /> T AP LICANT 0YS ING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x G Title G SO 23 Date��/0 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: S�y 00 rn4P A:rT0c-MED> <br /> /,{I,...�2I�DEPARTMENT USE ONLY <br /> Application Accepted By � �'/" �"M w• ' bz -pF Date Issued�J�i eO d Area Com( <br /> Grout Inspection Byr If ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> =T <br /> /CONDITIONS: I �j7 '1�...� <br /> '[' -If, ..Qi' ULC3L "J4P ,!WD 7nL . '�.S' ..i'. ir9 ZCF <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECC�K# REC'D BY DATE PERMIT/SERVICE REEQUEST# <br /> q 6 INVOICE <br /> U � eV 00 I DES <br /> C-57 LICENSED CONTRACTOR MUST SIGN LI NSE ORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />