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• 0 �-N-A L <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> W� <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 t 55 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin Count Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Healt Division. <br /> o F s„c <br /> Co OF— ICA STAR 5TR/; GA 13 Assessor's <br /> WELL Location <br /> CrosStreetC9P�iaL A�rmaCity La01 ZipgSay� Pa <br /> rcel# 005 '32A'25 <br /> C RC1 T, 13oKi0iS >f- 95 ZPhone# 2- 367 9 5� <br /> PROPERTY Ownle1r11 �A� I G P a Address (yal CAM41L AVE City L-oDT Zips qy <br /> C-57 Contractor WEST )4A2 OfFI Address3a33 Fi17-5Kl .I.D S+'Cify CAAQg°Pf ZIp957yaUc# 51'1 '�hone 914 - a7lp <br /> /� CC 1tiA�/ <br /> Consultant/Sub Contractor A • GA G . Address ` 005 VJ W 1)Sr,n City 57c,--KZPOLic# 22 Phone 2.0` 0}, <br /> GIS Coordinates:X ,Y ,Township � N Range 7 - Section,_ <br /> WORK TO BE PERFORMED <br /> )NEW WELL/BORING(CPT EOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# D OVER-BORE <br /> "YELL# ()PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE QiK if MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: 1,46 <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: D STEEL 0 PVC D OTHER: N)A <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 1„f-f f- DFl TI�TREMIE TYPE TO BE USED: D AUGERS HOSE <br /> D AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Ayes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER APPROX. BORING DEPTH )5 A F£4.f- 6i 4,D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?N I (if YES, list specifications here): <br /> COMMENTS: r � <br /> L J t C, IC r f Ca , wa <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEN 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,1 shall not employ persons subject to WORKERS'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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> ��JTHS APPLICANT MUST CALL 48 WORKING HRS IN VANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x / Title ate 3 <br /> SEE SIT AP IN UNIT IV WORK PLAN DATED: jY)PA,4 QK ZaQ� <br /> ,/,(/ DEPARTMENT USE ONLY �� �_ <br /> Application Accepted By 1� � Date Issued n Area Q <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date 1i3 O/ <br /> COMMENTS I CONDITIONS: ec <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 !3 3 22- OZZ•35Z <br /> C-57 LICENSED C NTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />