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COPY <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> OFF� <br /> ENVIRONMENTAL HEAL-EH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209r 468-3449 QQ <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/Qr 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 /> 135'5" W. ii nJ S}r,e4- Assessor's <br /> WELL Location Cross Street Comoro I-IollcrJ City I .ro_ Zip 95.3 6 Parcel# <br /> WP.S1• :Side, rr�5o,,}io/� iS-tr�c-}- <br /> PROPERTY Owner t.)ec4 Srdt Ns . Address City Zip Phone# $3 S- crSo3 <br /> C-57 Contractor /2Gis)o/l SaM al;,43 Address H11-0l 5. 50T—" City QiCV010A zip 7/ c Lic#6363Phone#&J 23�-yS,7S <br /> Consultant/Sub Contractor 6eoNI44Y;X Address 701 0ebSi&, Si /2 (City Oak IOAd Lic# Phone#,(Sl6463-9161l <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0NEW WELL/BORIN)(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER. OTHER-) []DESTRUCTION(choose type below) <br /> SOIL BORING# 3 - GMA-30, 3iy 32 []OVER-BORE <br /> []WELL# []PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES NO WELL CASING DIA: AIA <br /> a EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS A/A TYPE OF CASING: []STEEL []PVC []OTHER:_ <br /> a VAPOR []MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED: I]AUGERS []HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS,30') <br /> Q SOIL BORING []HAND AUGER APPROX. BORING DEPTH /S []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> a OTHER: []OTHER CONDUCTOR CASING PROPOSED? IV A (it YES,list specifications here): <br /> COMMENTS: 11.,ed ILsk dis Witt ro c. % /S inSla,6t +LWvr4L/, I" din_ yt l ta,s;z Screen fv Sa+w�(c=�io<.La4t.IZ. <br /> &IiA5 Oilh-c,k f i t 1 ed lei e e 4- reol VS,,15 e.�, a, — i n <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENC.ROACHMEN 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 WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting 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 /> WORKERS'COMPENSATION Laws of California." <br /> /���� <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x �U��l ""�/— Title P/o ieJ St,f,1,h54- Date — <br /> SEE SITE MAP I UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 49--/ _ 0.0 Area <br /> Grout Inspection By Date Final Inspection By Date ro ` G6 <br /> Destruction Inspection By Date <br /> Jolf <br /> COMMENTS/CONDITIONS: �� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> fib • a /0 .2 <br /> XO�:IaTCEI:�IS�:B&�QRI{���' <br /> UNIT IV-6/23/99/sign bkpg/MI <br />