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6 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAID} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 8-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> 'NELL Location 9909 E. lt����*1Dd� Iwo A Ur✓• Cross Street jg'054r City {�lq*y 7af Zip 53 Parcel#2y 3-z 7 <br /> PROPERTY Owner L a1YQ2i2'. �G C�� Address +' ' �HCYii City L()D I Zip Z0 Pphofne# Zc 333 <br /> S-57 Contractor V4� ��IU l����� Address %� e%� S/ Cit �0 /� Zi Lic#1- q�lP one# 701rr'3�`�' SjS <br /> Y_JL— .p <br /> Consultant/Sub Contractor t cy—�lo5E E / AddressZ9-127��tGWAti e�lC CitytL4E�C5rV Uc#'TPhone#2cC1 r-" V1 UZ`l 3 <br /> GIS Coordinates:X Y Township Z 600—�N Range 7 QST Section /d <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION (choose type below) <br /> O SOIL BORING# p OVER-BORE <br /> WELL# 'PRESSURE GROUT <br /> "Other: <br /> CMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS k <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE '9"+ MULTIPLE CASINGS?O YES WNO WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: 0 STEEL VPVC Q OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL 0- I TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes tNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING O HAND AUGER APPROX. BORING DEPTH Zc' O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? N 4 (if YES.list specifications here): <br /> COMMENTS: uJT[lc{ZC4�l �IG1I'cS Sc� Gi�7KEfEi� Gt;l� ' ��(/ 1flq'rtL <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i hereby certify that I have prepared this application and that the wore 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,l shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> :.ontracting 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 /> NORKMAWS COMPENSATION Laws of California.' <br /> THE APPLICANT MUST CALL�7RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title G 67^1 S U I DZ't Date 8� O 90 <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> /, DEPARTMENT USE ONLY <br /> Application Accepted By (/� (• "`�'. 4 Date Issued 3 /6 /� d Area Z ()I <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER I INVOI, <br /> 2g0Z , oo C�✓�� 3 e 015 220?5 <br /> UNIT IV-5/99/MI <br />