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WELL'PERMIT APPLICATION FT;RM 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) 468-3449 FILE` GO Y <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 /> cavOfry CI"BWvD p Assessor's <br /> oI <br /> WELL Location alQQQQ ^ rnfA.f QV8 GJU D Cross Street Eh,,k1K 14n Avf City si K-T�Zip ISZn"7Parcel# ��p ry� <br /> PROPERTY Owner <br /> Address2021 I�.(p,,�•*2_ _ ity s%sclC7�n ZipCI5Zo�Phone#,M�{36g2 - <br /> �q 2' <br /> C•57 ContractorlA)`GS, )447- Mcg/ f'r Address5}3E,4z$IerclO 5+ , city �n .c. ZipFS74ZLic#55�Phone# IIIb b 27(0 <br /> Consultant/Sub Contractor G, r r-• Address 700.5 N. WI'ISpn t`-f 1city 5 tncK7, Lic# o t Phone# p )Yb mzo b <br /> GIS Coordinates:X YTownship Range - Section z l <br /> WORK TO BE PERFORMED <br /> fNEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 1\ OIL BORING# 0 OVER-BORE <br /> WELL# M t 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `1 <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE SSS MULTIPLE CASINGS?0 YES�fp'�/NO WELL CASING DIA:Z ' Inc rr <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS sL�nVJ4 TYPE OF CASING: 0 STEEL AB,'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7- F6 C+ TREMIE TYPE TO BE USED: 0 AUGERSSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes bt\'fJo (NOTE: MAXIMUM FREE-FALL DEPTH I 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH ZS fF_ f£i- _,)JOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? ",% ( if YES, list specifications here): <br /> COMMENTS: C E 'er C'U <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 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 /> �THE APPLICANT MUST CALL 48 WORKING HRS IN A VANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x VY�� V/- r�.y�y--�"— Title C"�' �P�o �j Date MA,I� Z u PD <br /> SEE SITE MAPU UNIT IV WORK PLAN DATED: DEC�r blzig, 1 1995 <br /> DEPARTMENT USE ONLY '/ <br /> Application Accepletl By Date Issued Area /C <br /> Srout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date �— <br /> -OMMENTS I CONDITIONS: S� <br /> ACCOUNTING ONLY: AID# rArt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �jtiU) I(l W 42b-00 2.31 O I <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JNIT IV- 6/23/99/sign bkpg/MI <br />