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Sent By: Gregg Drilling & Testing, Inc. ; 925 313 0302; Oct-22-99 15:56; Page 2 <br /> L•PERMIT APPLICATION FORM <br /> F UNIT IV <br /> IV <br /> . � � - <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> NOV ( 1199 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) -f'y <br /> Vi: ONP Ei,iiAL HEM-IX- Weber, Third Floor, Stockton, CA-, 95202 49- v <br /> PERM! I / SERVICES (209r 468-3449 <br /> MON.REFUrIQADI,E PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joattwn County for a permit to construct and/Qr install the work described, This application is made In compliance with <br /> San Joaquin County Development Title. Chapler 9.1115.3 and the Stanaards of San Joaquin County Public Health Services, Environmental Health Division <br /> Els wm,� IQ,1 v/,, ql—1-?3 Assessor's <br /> WELL Location r Cross Streot 18leg, E� City f ar�ll i S TziogS-385 Pucci# 25's— <br /> S Ce- ftt s tn.- <br /> PROPERTY Owner i rT ict,trt .--ter_- AddressS' <br /> - 8�V �� city 0iiii", Zip Phoned! <br /> C-57 Contractor 6111 hr,ll,hj f ic�aY., i,K, Aadress `I50 MoWe.. L',-k-j CityPaH,nez Zip` rt'i5i Lico ` -1 Phoned C79:51 >r3 <br /> Consultant/Sub Contractor Ju_,r•,I t r ,flcr�if _Adoressllyl We?.rr5{cI `;fes 1144-dBrit CityG(vYWtlri �Lic* Phones(5V)66 5 - JyctX <br /> GIS Coordinates:X Y Township _Range Section <br /> WORK TO BE PERFORMED � - <br /> NEW WELL l BO_ RfdG(CPT, GEOPROBE. HYDROPUNCH. HAND-AUGER, OTHER-) U DESTRUCTION(choose type below) <br /> SOIL BORING f If a OVER-BORE <br /> (] <br /> 'other, WELL a 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF VuEL4 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING )f HOLLOW STEM OIA, OF BOREHOLE MULTIPLE CASINOS?D YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS... __ -_ TYPE OF CASING: 0 STEEL Q PVC ()OTHER: <br /> 1]VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED- 13 AUGERS (]HOSE' <br /> (]AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> SOIL BORING0 HAND AUGER APPROX. BORING DEPTH (] BOLTED TRAFFIC BOA or Q STOVE PIPE <br /> (]OTHER: I] OTHER CONDUCTOR CASING PROPOSED? (It YES,fiat specifications here): <br /> COMMENTS: <br /> NOTE:_ OFFSITE 60RINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certlfy that I ho.e prepared this 2pplieallon and that the work will be done in accordance with Syn Joaquin County Ordinances,Stat*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 thi;permif 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 worn for which this permit is Issued, I shall Employ persons subject to <br /> WORKERS'G PEIVSATIOfV Laws or Caliromia,' <br /> HIEE APPLICANT ST AL 48 HRS IN ADVANC�E^FOR ALLREQUIREDINSPECTIONS. <br /> Signed s -_.. Tllle �r �/ 2Bote lo Ar17 1 <br /> SEE SITE MP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> application Accepted By 4j',.0 Date Issued Il g4 t o O Arms rV 12 w6L U7 <br /> Grout Inspection By Date Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS S Z7 S i <br /> ACCOUNTING ONLY: Alps PACO <br /> PE CDOES FEE INFO AMOUNT REMITTED CHECKOdCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ;- o S r - 79C,I <br /> Ga E � ..:. , <br /> UNIT TV. 6/23/99/sign bkpg/MI <br />