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Sent By: Gregg Drilling & Testing, Inc. ; 925 313 0302; Oct-22-99 15:56; Page 3/5 <br /> ELL PERMIT APPLICATION FORM UNIT IV <br /> N«� 1 1999 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES e5X S <br /> TAS-HEpgWIRONMENTAL HEALTH DIVISION (PHS-EHD) p4 cd- le <br /> p�Vjvl_� <br /> -ICEJ04 E. Weber, Third Floor, Stockton, CA_, 95202 <br /> E�iUIFt IT I `.;tR �� <br /> PFM (209 468-3449 <br /> NON-RFFUN0A9LE PQRMIT F-SPIRES 1 YEAR FROM DAT17 1$SUED ( <br /> Application is hereby made to San Joaquin County for a permit to construct an(I)w install the worn described_ This application Is made In compliance with <br /> San Joaquin County Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br /> S 27 r Assessor's <br /> WELL Locadon ecj Kd CrossStreetV11b F—An city VSA-fA15 Zip`�5385 Parcel* -.55-9?-41 <br /> PROPERTY OwnerN...,l<.' N�;wow LII r'L. c/t!US It+e .Pddrecs l�� �rMM�Ze !ln. —city(a»k RicoA. Zip�40 Z_PhoneU_ <br /> C-S7 Contractor L)t- Address`5c) W69- P,u� City/1}crf�+hck_ 2ipy'1y53 Lich lFz PhoneAt�'13�)3l3 -5$xi� <br /> Consultant/Sub Contractor bn�s Address LI) lt4b5jpr­ SJ. 11"A24-City 0101d Liar Phones*�Slo�f�j-41uo <br /> GIS Coordinates-, X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/,BORING ( CPT. GEOPROSE. HYDROPUNCH, HAND-AUGER. OTHER') n DE=STRUCTION(Choo6e type below) <br /> SOIL BORING a `t o OVERBORE <br /> "Other. WELL a a PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q'HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? Q YES [)NO WELL CASING DIA: IN <br /> 0 EXTRACTION rQ AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING (I STEEL Q PVC Q OTHER: V) <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS OHOSE 4'' <br /> [I AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> SOIL BORING d HAND AUGER APPROX. BORING DEPTH Q BOLTED TRAFFIC SOX or 17 STOVE PIPE <br /> Q OTHERR o OTHER. CONDUCTOR CASING PROPOSED?_. (It YES,Fist speclAcations here): (�.. <br /> COMMENTS: �p <br /> - s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prupamd this application and that the work will be done in accordance with San Joaquin County Ordlnanera,State Laws,and Rules `L <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature cartirws the following: "I certify that/n the performaoco of the work <br /> for whlch this perrtrlt/s/$sued,1$hall not errrproy persons subiject to WORKERS'COMPENSATION Laws of Califorrtls." Contractor's hiring or sub- <br /> ContraCling signature certifies the killowing: -/certify that in the peilormanCB of the tvork for which this permit is issued, l shall employ persons subject to <br /> WbRKERS' OMPI`NSATION Lairs al Cahibmis <br /> APPLICAN MU/ AJLL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> Signed a / ' L���'�-1 Y ^---- TI11t Date <br /> SEE SITE MAP IN UNIT IV WORK PCAN DATED <br /> DEPARTMENT USE ONLY <br /> Applicatlon ACceptcd By � Date Issued <br /> Area <br /> Grout Inspection By Date Final Inspection By� Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AlDlll <br /> FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKAWCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 967 602(f (I <br /> _ - <br /> UNIT IV-b/23/99/sign bkpg/MI POMPANO= <br />