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WEL , PERMIT APPLICATION ORM UNIT IV r <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 <br /> ' <br /> NON-REFUNDABLE DEBRA`EXPIRES I YEAR t=ROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instaN the work described. This application is made in compliance with <br /> San Joaquin County Development.Titie,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location 3 CI Assessor's <br /> ` a 1 Cross Street City Zip S�Parcei# ' <br /> E PROPERTY Owners �nur t�5 �GcGdln� F - <br /> Address <br /> City . Zip_04C,�Phone# oto"1 <br /> i- C-57 Contractor <br /> —ALL.Address. L(DDS �f <br /> City L Zip_ Q5`Lic# Phone# <br /> r <br /> Consultant/Sub Contractor <br /> Address /V. City oc - Lie# Phone <br /> GIS Coordinates:X 4_ <br /> Y Townshi f <br /> p Range y Section t <br /> WORK TO BE PERFORMED <br /> k4EW WELL/BORING(CPT,GEOPROBE HYDROP <br /> UNCH HAND AGER, OTHER ) <br /> U <br /> OIL BORING# D DESTRUCTION(choose type below) <br /> D OVER-BORE <br /> `Other; WELL# 0 PRESSURE GROUT <br />{ <br /> Comm <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 't <br /> 0 EXTRACTION MULTIPLE CASINGS? YES VO WELL CASING DIA: }� <br /> 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ n+�/� TREMIE TYPE TO BE USED; <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED; 30' <br /> 0 AUGERS �i <br /> p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 5<SOIL BORING f1 HAND AUGER APPROX. BORING DEPTH t <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER s CONDUCTOR CASING PROPOSED?- NA {if.YES,'list specifications here): <br /> .:•fir' <br /> COMMENTS: <br /> } <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: "l 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: 7 certify that in the performance of the work for which this permit is issued, !shall employ persons subject to I <br /> WORKERS'COMPENSATION,Caws of California." { <br /> TIJ9 APPLICANT M ST CALL.48 WORKING HRS IN AD,VANCE FOR ALL REQUIRED INSPECTIONS: i <br /> (tom / ... ....._...___.. _ _ .-.; <br /> Signed x Title 2iT� tG7� t 3 [b <br /> .. Date <br /> SEE SITE MAP IN UNIT IV WORK .PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued - -00 Area O 7 <br /> Grout Inspection By Date Final lnspection Sy <br /> Destruction Inspection By G Date <br /> Date t-1%�kip <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3SV/ (`! — 5 13yS3 C,_-) 311-7100 <br /> C-57 LICENSED CONTRACTOR MUST,SIGN LICENSE&WORKERS'COMPENSATION DECLARA'�ION <br /> UNIT IV- 6/23/99/sign bkpg/MI - <br /> i <br />