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�Nx' �" M <br /> •LL PERMIT APPLICATION FORM <br /> 5 <br /> R�' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ON5( e- <br /> L�' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � 2 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ) <br /> NON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcatlon Is hereby made to San Joaquin County for a permit to construct endlor Install the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> / Assessor's <br /> WELL Lgcatlan�SG1 �d./p/GO Cross Street T dGly /J�7JP. .ParceutZYG-/ <br /> PROPERTY Owpoc o, � ✓ wi..n::T Address�SlJ l�I�,®II�Cily r ZIpP.S_3 t Phgne#�98Zo ��dB <br /> tA&,p;LCayP9f <br /> C-67 Cantmoto G SUdfjg.-sPhone#925313 <br /> .S8od <br /> Esc <br /> r111 rPhone#9 <br /> Consultant/Sub Con7aclor� /7dres � � " oPr <br /> GIS 693r' �S-5D <br /> Coordinates:X,/±L a5-Yom"'" -1.-.-�---L YZ'S�'YY'f•Township 6ZS Range 06Section �3 <br /> WORK TO BE PERFORMED: - <br /> EW WELL I BORING(CPT,GQ OVEREOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose <br /> ER type below) <br /> Q SOIL BORING -BORE <br /> N # E <br /> ELL# l77l�'y �PRESSURE GROUT <br /> Other: <br /> COMMENTS: <br /> • TYPE OF WELL INSTALLATION TYPE CONSTRUCTK)N SPECIFICATIONS <br /> `� \ MULTIPLE CASINGS? YES ()NO WELL CASING DIA:Z i1 <br /> yMONffORING HOLLOW STEM DII�OF BOREHOLE \' <br /> /U-EXTRACTION /IJ AIR HAMMEPJDRNEN CASING THICKNESS TYPE OF CASING: STEEL A PVC\ � OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL G7/lG TREMIE TYPE TO BE USED; GAUGERS OHOSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes Q (NOT :6 SID T FR BOXrC��DTOVE PIPE <br /> SOIL BORING p HAND AUGER APPROX.BORING DEPTH <br /> Q OTHER: fl OTHER CONDUCTOR CASING PROPOSED4//6 (It YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT <br /> I hereby certify that I have prepared lhla appicatlon and that the work will!u done h accordance wlth 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:"1 of California.-In the perfamence gorse work <br /> for which this PermR Is Issued,l shall not employ persona subject to WORKERS'COMPENSAPON Laws of Contractor's hiring or sub- <br /> for <br /> slgnature certifies the following:7 certify that M <br /> the perlormence of the work for which this permit is issued,I shall employ persons subject to <br /> RKER MPENSATiONLewaalCaliPomla.- <br /> e C LTHE UNIT a%Ca <br /> 48 WORKING HRS IN ADVANCE <br /> 11FOR <br /> yALL REQUIRE INSPECTIONS <br /> —� TklelComPanY�e�/drd7a T/�0%5/.l�/ /Z.75'/1 /J7/G�°�1�,✓. <br /> Signed x <br /> Print Name L ✓//!iS /ii �`�P_..1 Data �// !/6 z-- RC.V> <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 42a IoZ <br /> DEP TMENT USE ONL <br /> Application Accepted BY Date Issued S-3 2 Date �,L�'02 <br /> Grout Inspection By Date Final Inspection 8 <br /> M <br /> Destruction Inspection B Date <br /> COMMENTS 1 CONDITIONS- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REM17TEo CHECK IF RECD BY DATE P <br /> E REQUEST� INVOICE <br /> Aot A, cn— 555v 5- <br /> 5/15/20DD <br /> -u H1dId CEPE89060Z 61:9t 000Z/9t/90 <br /> 60 39tld <br />