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UO/ [.U/ cUUrJ U7: DL <br />G3E �C`E � WED <br />OCT 2 3 2001 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />LU'7ubCj`l .J ,i <br />r lt- i H r LUUht <br />WELL PERMIT APPLICATION FORM <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHO <br />304 E. Weber, Third Floor, Stockton, CA-, 95202 <br />(209) 468 -3449 -ORIGINAL <br />NON-REFUNDABLE PERMrf EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct andior install the work desc bed. This application is made in compliance with San <br />Joaquin County Development`Ttle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environment@( Health Division. <br />WELL Location LOBI LS •'(` tmoca�Ro' • Cross Street Ci j,�w Assessor"s <br />�1� �Q���'(('' ty�-i�o1r11 zip �SdGa�l Parcel# II3- 1�IlJ-Oo1, <br />PROPERTY Owner Ltn►Je�s►-w�� `i�P AU'C 4ddress�i(gol P&C.-F L. Av,e Phoneit ti - :51ti <br />C-57 Contractor �s' Sddress 4005. City tNy Zipg <J p�{p38� Phaneis rjld'.i3i- 575 <br />Consuttant / Sub Contractor >GVN��VOZ�T» dress 1�a : 1 Pvs.t+� k4 City[rtu�.�,a <br />5L ic1R Phone# 6q, )-' (i4 - 41,$00 <br />�O� •c. +t - ISO <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />[l N`EW WELL I BORING ( CPT, GEOPR08E, qYDROPIJN HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />a 501L BORING >Y 1 OVER-eORE <br />,9 HELL # PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING O HOLLOW STEM DIA. OF BOREHOLE A.,S. tr MULTIPLE CASINGS? iYES ONO WELL CASING Offl,;'. a," n <br />0 EXTRACTION O AIR HAMMER,'DRIVEN CASING THICKNESSA(- TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED: O AUGERS OHOSE <br />0 AIR SPARGE [.}'PUSH POINT GROUT SEAL PUMPEO: D Yes U4o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Z SOIL BORING p HANO AUGER APPROX. BORING DEPTH' W W- Q BOLTED TRAFFIC BOX or O STOVE PIPE <br />OTHER: OTHER CONDUCTOR CASING PROPOSED? 46. '. <br />D O ( YES, list speaFcaGons here}: <br />COMMENTS: <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 Rul-s <br />and Regulabons of the San Joaquin County_ Homeowner or licensed agent's signature certtftes the following: '7 certify that in the performance of the work <br />for which this perm;t is issued, t shall not employ persons subject to WORKERS' COMPENSA T70N Laws of California_" Contractor's hiring or sub- <br />contracting signature certifies the following: "1 certify that Irr the pertormance of the work for which this peemit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of CalrYomla.' <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x k Title/Company 1 <br />,, / f <br />� <br />Print Name Y A t�� 5-4-ec �n Date�a3✓�% <br />SITE FILE ADDRESSIWORK PLAN DATE: <br />Application Accepted By <br />Grout Inspection BY__.!!i fh U Date <br />Destruction Inspection By Date <br />COMMENTS/ CONDMONS: <br />/ <br />Inspection By <br />i;'7_1 \O,(1 W - <br />i <br />ACCOUNTING ONLY: <br />AIDS <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK A <br />RECD BY <br />DATE <br />PER VEST a <br />INVOICE <br />ak_ <br />r1' <br />sRit��'Z���16 <br />C-57 exp- WC/waiver_ C-57 Letter of Authorization to sign permitg� Encroachment doc(s). 5/17/00 <br />e <br />04 <br />