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WELL PERMIT A PPLICATIONORM <br /> UNIT 1V <br /> �k 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. { <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)'468-3449 <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 9-11'15.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> _ 6 v Assessor's <br /> WELL Location rg 5 out,S e R)[ CrossStreete0 Zip 9533+ Parcel# <br /> PROPERTY Owner R,-e_6 Pro.Pµc7s e Address / �8ox s-077 CityS"eAC. Ar,�_Zip�b <br /> C-57 Contractor W e-Sze-x ___ _Address ISO d ex l,g re,/ City�` 5--C Zip936 Pj Lic#Ea1'V hone#97Z 3 73-//(8 <br /> Consultant/Sub Contractor S 7%6 7t4 S 45(J1✓0A<e4)1ddes5Do Gn+_er .c t0ita CityCa+aehone# 475^644 <br /> GIS Coordinates:X Y Township Range Sectioh <br /> WORK TO BE PERFORMED <br /> ,6NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> D SOIL BORING# p OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT r <br /> "Other: <br /> COMMENTS: -J M yJ-,2 1 Il? W ' 3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> If MONITORING J HOLLOW STEM DIA. OF BOREHOLE CO 1 t MULTIPLE CASINGS?0 YES #NO 1 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 01 PVC p OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREM€E TYPE TO BE USED: d AUGERS QHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 2 ? 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here) <br /> COMMENTS: mob 9i, CO <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM "MITS <br /> I hereby certify that;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: '9 certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California.';',Contractor's hiring or sub <br /> contracting signature ifies the folio 71 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKERS'CO NATION s of a fomia. <br /> LIC N MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title ec <br /> 11�� ti -e Date J DCS <br /> SE SITE AP IN UNIT IV WORK PLAN DATED Mni,el 17 zd0J <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued i O CJ Area <br /> Grout Inspection By Date 6 [ 3 OQ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> �3 <br /> FAC-# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMfT/SERVtCE REQUEST NUMBER INVOICE <br /> � svI �g9 .c:' 0 13Tt+ l;:T3 S '100 S R# oozzg S <br /> C-57 LICENSED CONTRACTOR MUST-SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br /> s <br />