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nR A }y� <br /> ��1rI <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ojoe:� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-34 9 WIK4- <br /> NON-REFUNDABLE <br /> PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County-for a permit to construct and/or insta l 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 Jo quin County Public Health Services, Environmental Health Division. <br /> Assessor's . <br /> WELL Location I++ sec�,e.. 1;fn Cev►lyrl. Cross Street l l �` t City„ T m" Zip 9 6376 Parcel# C aTr Tnc <br /> PROPERTY Owner G� °� Tca.c Address 3ZS C- ZO-It, 5k-mCity Tr�aa _Zip qS3 76 Phone#2�{-83r- tZO <br /> i?d.,c1+a � <br /> C-57 Contractor CASe I)^Iltn Address 363% Omcca CGficle ity �r6a" Zip RSy`f2 Lic#217SrO Phone#416-638- 1169 <br /> it"k, <br /> Da�tid e�ae� ►Q'`„c1.o 7_?-%I Phone#516-69 t- 1300 <br /> Consultant/Sub Contractor Gei er-4+ an S„c• Address3140 <br /> G,Id G,w Dr t7o City��nyw Lick <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> g NEW WELL f BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) ADESTRUCTiON(choose type bel ) <br /> SOIL BORING# tKOVER-BORE <br /> a WELL# Q PRESSURE GRO T <br /> 'Other: [J <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ©MONITORING U HOLLOW STEM DIA.OF BOREHOLE wl MULTIPLE CASINGS?II YES ONO WELL CASING.DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'PREMIE TYPE TO BE USED; Q AUGERS HOS <br /> (S AIR SPARGE a PUSH POINT GROUT SEAL PUMPED es p No (NOTE: MAXIMUM FREE,-FALL DEPTH IS 30') <br /> SOIL BORING ©HAND AUGER APPROX. BORING DEPT <br /> d '�'�]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> Q <br /> OTHER:_11 OTHER CONDUCTOR CASING PRO OSED? (if YES,list specifications.here): <br /> COMMENTS: f <br /> NOTE: OFFSITE BORI GS REQUIR�ACKESS OR ENCROACHMENT PERMITS . <br /> prepared this application and that t <br /> I hereby certify that l have he work will be done in ccordance 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: "t certify That in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKER 'COMPENSATION Laws of California.” Contractor's hiring or sub- <br /> contracting signature certifies the following: `7 certify that in the performance of the w rk for which this permit is issued, l shall employ persons subject to <br /> WORKERS COMPENSA TION Laws of California.” <br /> T PP <br /> MUST CALL 48 WORKING FiRSMIN A VANCE FOR ALL RE4UlRED INSPECTIONS: <br /> Signed x <br /> Title e„,or ty� Date <br /> SEE SITE MAP 1 NIT IV WORK P N DATED: <br /> DEPARTMENT USE ONLY Q <br /> Date Issued 7 �Q/ Area <br /> Application Accepted By --� <br /> Grout Inspection By Date Final Inspection By s <br /> a ---�� <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: ,. ..� •/1 .O <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK'# RECD Y DAT PERMIT i SERVICE REQUEST# INVOICE ; <br /> x'02 w 1000' <br /> C'S_7_LICENSED CONTRACTQRpMUST SIGNLICENSE„ „WO _ ;• �,_S' COMPENSA'ITON3llECLARATi <br /> __�.... . . . . _ ON <br /> UNIT IV-6/23/99/sign bkpg/MI <br />