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WECTLr PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES llECI NEEDi <br /> ENVIRONMENTAL)HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 2 2 2002 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT,/SERVICES <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 /> WELL Location ��0 N• CACI f-, 57 Cross Streets'-/41NER Assessor's <br /> y ) City S%dGfc(O1( Zip�S2y2 1`arcel#_/3y-2s"O—OS- <br /> PROPERTY Owner. IT� F STOG�Tah A-ddre_s$ l h' �Lt7Ol j <br /> 5114 10 4 uw.q a Zip 5e-Z Phonet{ <br /> C-57 Contractor_U IZO(.1 EX Address <br /> �7 Cit �%Zip9ic#��S9z,�Phon�S/o)266-Q966 <br /> Consultant/Sub Contractor 2KPDRO--4 tc Address�� <br /> 3 <br /> ---� .3 City.I"1%. Y/tl+�lic#h'G�S Phonegr6 s"o�SfZB-o S�� <br /> GIS Coordinates:X , Y , <br /> WORK TO BE PERFORMED Township Range Section <br /> 0 NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> 0 WELL# 0 OVER-BORE <br /> 'Oth eeC - 05 O ��i�/ r 4 o Q PRESSURE GROUT <br /> COMMENTS C /3ACF-G/CLE-Q w/Ty f/CA1 C �r-tC wT <br /> s>Y /fCGOROfTNG F wiTH NC �PPQOVf� (,voefc �LAn, — Sart <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIcoOE 3�`j <br /> ON <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE / " MULTIPLE CASINGS? <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �YES O WELL CASING DIA: <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> Q AIR SPARGE 'PUSH POINT AUGERS OHOSE <br /> GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'OTHER: o OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS:PRU/3ES TO RE St�cED /r� •�c p1 .9Tc c `/ ,4� f/Z 5,9,,,pL/.vG <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'COMPENSATION Laws of California." <br /> TH"PPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x ''rrpTitle TTYj�1-OCE-0Lb61STDate1 /16 /Dt <br /> SE IIN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By /�,�, , � Date Issued Z �/ `� Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date Z O 7 <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> s0 3 I z z /� oZ oa 2��iS `t 31 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />