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MMAL <br /> *% 1. • W <br /> WELL PERMIT APPLICATION FORM UNIT ►V <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> -EHNiPY 5200 ENVIRONMENTAL HEALTH DIVISION A., 95202 il <br /> 4 E. Weber, Third Floor, Stockton, CA., 95202 � <br /> i'diP.GN`tlE;JTAL HEALTP (209) 468-3449 <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication 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 /> ;an Joaquin County /Development <br /> /Title,Chapter 9-1115.3 and the Standards of San Joaquin Cou/nty�Public Health Serve.EnvirAssessoals Health Division. <br /> TN121't1 -Cross Street City f�1LZ Z�P�-7 L� Parcel# <br /> YELL Location ? �Tjj <br /> PROPERTY Owners Z<P'r�r,r rl Address PU G P'JillCity <br /> 0 vill <br /> -57 Contractor <br /> �1Jst1�Z Address 233 'n C City iP� IC#22 1 hone#`l/U�3� 727{ <br /> ,,�nje Addres .0 ji f D;h 1 IA}��1"Jidity Shc22 `ty## Phone# 0 Jig <br /> ;onsultant/Sub Contractor/7t' <br /> 315 Coordinates:X <br /> y.,Township Range Section <br /> NORK TO BE PERFORMED <br /> *EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> BI,SOIL BORING# / D OVER-BORE <br /> WELL# p12,- <br /> .C...W�� PRESSURE GROUT <br /> 'Other:. � � �7 o � /uy,yy/2• <br /> COMMENTS <br /> v n tl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> v1ONITORING p&OLLOW STEM DIA. OF BOREHOLE rI MULTIPLE CASINGS?D YES ,g NO WELL CASING DIA: L <br /> TYPE OF CASING: D STEEL D PVC BOTHER: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: AUGERS DHOSE <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes ���� MAXIMUM D TRAFFIC BOX o <br /> C FREE-FALL� TOVE P PE <br /> DEPTH IS O I <br /> D SOIL BORING D HAND AUGER APPROX. BORING DEPTH /5L <br /> D OTHER: D OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here):— <br /> COMMENTS:— <br /> NOTE: <br /> ere):COMMENTSNOTE: 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: 11 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." <br /> CALL THE UNI'T/ IAV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> (/1 rlt'a( �l 'C=0I4V6) Sf� <br /> Signed x r � Title/Company * <br /> Print Name W ' �!I Hi �( rn�i Date <br /> SEE SITE MAP IN UNIT IV;WORK PLAN DATED: <br /> DEPARTMENT USE ONLY l D� <br /> Application Accepted By <br /> Date Issued Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONI 111,11P011 S <br /> UNTING ONLY: AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />