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Y <br /> WEL RMIT APPLICATIONIM 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 /> (209) 468-3449 h I <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED i <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 /> 1 <br /> WELL Location S�'t7v1 q q r n Assessor's <br /> � 7 I / / Cross Street City �J ! Zip Parcel# <br /> PROPERTY Owner te�r/! rn] EL-AAJ- 3 Address ��� �yA;t City 5 ;;4�-Fivv Zip'752(7 P one# q76 <br /> C-57 Contractor f�hY. of f(` !�I Address �� v , `� '� `157cf r r`i7Z�/7 �` <br /> f y. _ C Zip Lic# Phon� <br /> Consultant/Sub Contractor444-ox ddressAV5/VA77 h." lit ,9 <br /> y—CI'I� 1- # Phone# 7 <br /> Gly Coordinates:X Y Township , Range Section <br /> 4 <br /> WORK TO BE PERFORMED EW WELL WELL 1 BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER' <br /> 0 SOIL BORING# ) i' (] DESTRUCTION (choose type below) <br /> 0 WELL# It 0 OVER-BORE <br /> *Other: o 0 PRESSURE GROUT <br /> COMMENTS: II q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 I <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE 11 MULTIPLE CASINGS? 0 YES B'f O WELL CASING DIA: Zlt <br /> 0 EXTRACTION 0 IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL TPVC 0 OTHER: <br /> III APQR 0 MUD ROTARY DEPTH OF GROUT SEALI TREMIE TYPE TO BE USED: (]AUGERS OH05E <br /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 YesNo '(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 OIL BORING 0 HAND AUGER APPROX. BORING DEPTH 1 1 VE � r i <br /> j fOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i 0 OTHER: /Vo0 OTHER CONDUCTOR CASING PROPOSED? <br /> (if YES, list specifications here) <br /> COMMENTS; EA i e- a /1) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS E <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San iJoaquin County Ordinances,State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this permit is issued,1 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." 4� i <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR A�fL REQUIRED INSPECTIONS. <br /> ,I / <br /> i. Signed x l� Title�lEa_�O 3�I _Date '�f xz + <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> p I <br />` DEPARTMENT USE ONLY �P <br /> Application Accepted ByIN Date Issued_ 3' <br /> Area } <br /> Grout Inspection By W Date 'n Final Inspection Bya _ Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: E <br /> i <br /> ACCOUNTING ONLY: AID# I� <br /> rt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE 4,1ERMIT i SERVICE REQUEST# INVOICE <br /> �% � Z Z. 1 <br /> I li !,R# <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />