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WELIAERMIT APPLICATION FAM 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 />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 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br />Assessor's <br />WELL Location 221 41,42 c4. Cross Street j<cy ik-O-C. Cityktf 't)ifa._ Zip qC34:6 Parcel#47Z <br />PROPERTY Owner E (Sit." ; Address ..223 ce:A4lc,ity,19:te-1._Zip.9c3 . Phone* Sq9 Gyo3 <br />C-57 Contractor lit-ej . Address ra x- cf/e.. Citafsktz Zip?5C(// Lic# 7,20itlyp h on e#9/‘ - 722- V/06 <br />Consultant / Sub Contractor nib r.." cic,..vL. Address /9(..)4 /227 f,,r( City 111ff4j- Lif#10 17 3 I Phone#,:..2eN <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( <br />*Other: <br />CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />ASOIL BORING # <br />U DESTRUCTION (choose type below) <br />U OVER-BORE <br />a PRESSURE GROUT 0 WELL # <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />CASINGS? a YES U NO WELL CASING DIA: O MONITORING <br />O EXTRACTION <br />0 VAPOR <br />O AIR SPARGE <br />ASOIL BORING, <br />a OTHER: 6e....e,C <br />HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />PUSH POINT <br />0 HAND AUGER <br />DIA. OF BOREHOLE MULTIPLE <br />CASING THICKNESS /1/4- TYPE OF CASING: 0 STEEL 0 PVC U OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications 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 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, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x/C Title CA:,-(•-•-c,A Date /0 <br />SEE SITE MAIN UNIT IV WORK PLAN. DATED j-/<c 5-17 - <br />Application Accepted By <br />Grout Inspection Inspection By <br />Destruction Inspection By <br /> <br />DEPARTMENT USE ONLY <br />Date Issued it II 4/0 sZu. <br />Date I )02; IC Final Inspection By <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE r -' - v z Q'tStNUMBER INVOICE <br />3S-0 1 il C69 ta° 511 At "elf; . SROL3 I 9 1 3 <br />C-57 LICENSED CONTRACTOR MUST SIGN, L10ENSE.&WORRS MAIIONO1CLARATION <br />UNIT IV - 6/18/99 /sign bkpg/MI