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WELAERMIT APPLICATION FuRNI <br /> <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Apolication 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 Detaelooment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location 22,3 (..f.,,,i4Z14,3,41.„5 <br />Assessor's --- <br />Cross Street Ke 7 et, City I. ' - Zip Parcel# <br />- <br />PROPERTY Owner/aura 4 ri$4 ,...e...,.' Address A2 1 44sL:All'em... City i .7, 4a... Zip 95536Phone# $#9 5 ri7,3 # <br />C-57 Contractor 1/14* (X} Ore/(7_Address 6b 7r 5 r cityt,,,1Jic2ipgirs7 1 Liceneldrhone#9/4-,27* WOO <br />Consultant i Sub Contractor /4(37 Klo be t *LK -L. Address 6?C213)IC$>L 9 $4. I Cityn 41c si,..1.1c# Phone# Mit y ??Y' fa <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />WORK TO BE PERFORMED <br />A,NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />,JELL # <br />El DESTRUCTION (choose type below) <br />a OVER-BORE <br />a PRESSURE GROUT <br />'Other: <br />COMMENTS <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />A-MCNiTOR!NG ,<HOLLOW STEM *DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS aHOSE <br />a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />O OTHER: CONDUCTOR CASING PROPOSED? ( if YES, list specifications nere)' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />hereby certify that I have prepared this application arid 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: "I certifk that in the performance of the work <br />for which this permit is issued, shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued. (shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.'' <br />E PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />COMMENTS: 4i- c.,e,r- I— a 715,rati Cafj A0190 <br />Signed x ( Title eSiZe_frit Date O <br />SEE SI E MAP IN tfNlT IV WORK PLAN. DATED 'f-2q- <br />DEPARTMENT USE ONLY <br />Application Accepted By (ikk\-4 AAA t'or Date Issued ç Area <br />Grout Inspection ByLAyawsrc/u-, Date -{-i?t.-4-100: 1 Final Inspection By Date <br />)C, CI <br />Destruction Inspection By Date <br />—FIT") <br />COMMENTS / CONDITIONS: <br />if ACCOUNTING ONLY AID* <br />FAc# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE :11r.--- •itigirMir-T*-1114--2:-. , BER INVOICE <br />' --S--C 11 ' 0 0 ( 3 3 MEM - • 0 0 1)`"5 <br />C-57 LICENSED. CONTRACTOR MUST SIGN LICENSE. Lic WORKERg. MPENSATION DELAtAT1ON <br />UNIT :V - 5/18/99 /sign bkpg/Mt