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KATION IRM UNIT IV <br /> WELL PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTALHEALTH iaor, S olVISIN cktoO CAH 52x20, <br /> 304 E. Weber, Third <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for <br /> 15 3permit <br /> the Standards ofiSan Jolll thew <br /> n Cou ori�ny Publ c Health Sery ces Envescribed. This application is ironmental Heals Divis on. <br /> Assessor's .7 p20-3f <br /> San Joaquin County Development Title,Chap r Zi Seo 2_ Parcel# i 3 <br /> ry Cross Street �a ^-k 61- City 5� k P �— <br /> WELL Location l66 S I-�ct�c [Ik tv �„� Zip SG2 Phone#(q 14 71 -32o, <br /> PROPERTY Owner [��,«.� C'^ Address 9786 k B City <br /> Address City <br /> ip r1 S7gZLic#7 t 7 S(O Phone#LJ 16 16 3`8'1 1 6°1 <br /> C-57 Contractor Casra[�e �� t ti �tl6 63 f-17,�D <br /> �.}�r-P.Y o.J. (^4• 'pn f 7o City�aLt��SPhane# <br /> C�«-�r Address 3l(0 C1oI� <br /> Consultant I Sub Contractor Slca Section <br /> Township Range <br /> GIS Coordinates:X Y _ <br /> WORK TO BE PERFORMED a DESTRUCTION(choose type below) <br /> NEW WELL I BORING(CPT,G€OPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) a OVER-BORE <br /> a SOIL BORING# a PRESSURE GROUT <br /> [g,WELL# w-tl ti.rd� Mw�l6 <br /> "Other: <br /> COMMENTS: CONSTRUCTION SPECIFICATIONS Z " <br /> TYPE—WELL tNSTALLATiON TYPE ,, 7 YES NO WELL CASING DIA: <br /> MONITORING 0HOLLOW STEM DIA.OF BOREHOLE��MULTIPLE CASINGS. a VC OTHER: <br /> E7 .��_ <br /> AIR HAMMER/DRIVEN CASING THICKNESS �TYPE OF CASING: a STEEL <br /> D EXTRACTION a <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 4IS 78 r TREMI€TYPE TO BE USED: AUGERS <br /> OSE <br /> EE-FALL DEPTH IS <br /> AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a'Yeos� No64 D(NOTE: MAXIMUM <br /> OL En TRAFFIC BOX or a STOVE PIPE <br /> a°7 <br /> a SOIL BORING a HAND AUGER CONDUCTOR <br /> BORING DEATH <br /> a OTHER: —a OTHER <br /> CONDUCTOR CASING PROPOSED?�.�._(it YES,fist specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENTtn � tPERMIT Saws,and Rule <br /> I hereby certify that l have prepared this app <br /> lication and that the work will be done in accorda !certify that in the performance of the wor <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: f Contractors hiring or sub- <br /> for WO <br /> TiON <br /> which this permit is issued, f shall not employ persons subject toperformance OfRthe work for PENSA perm <br /> contracting signature cit is ssued,Laws of lIshall employp ing: "I certify that <br /> WORKERS'COMPENSATION Laws of California." <br /> T P I NT MUST CALL 48 WORKING HRS IN ADVANCE-FOR ALL REQUIRED INSPEECTION . <br /> Title <br /> �n %S� Date J O <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: o <br /> DEPARTMENT USE ONLY Area- � <br /> Date Issued� <br /> Application Accepted BDate <br /> y <br /> Ddte Final inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> REC'13 BY ,DATE= PERMIT!SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 0CQ (c,62 D4:5 <br /> 50� 0 . D5 �5 <br /> C-5 <br /> 7-LICENSED CONTR ACTOR'NIUST;:SIGN•LIGERS',CONiPENSATION DECLARATIG <br /> UNIT IV-6/23/99/sign bkpg/MI <br />