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WELL PERMIT APPLICATION FORM 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 <br /> ILE COPY <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 /> WELL Location:Z151 CIV6 <br /> FFR�Kti/(1 0VL' S Assessor's <br /> o rn4fNJ VIS G IVOCross StreetC, . r City Toc-KTno Zip LS2a'7 Parcel# <br /> (�1 Ar� IVO <br /> PROPERTY Ownefj]IyO, rty to S£ayil.e Address 2IS1 C„✓,4r y C IR&MvOCity 57oc.K9nn Zip 95 1 O7Phone# Zo Vb0 2715 <br /> C-14 oFlr✓ F4AKK& aAn�y C I <br /> C-57 Contractor IAIEST A2 W.-t- Address3Z33 F;47. r(-Io !S+( c�City cr.rnr.,,c_ Zip $9?YZ.Lic#Ssyy7phone# 3� IT 76 <br /> Dfilli '+ Wc.1 <br /> Consultant/Sub Contractor G , Address_7ooS N . LvrlSon City S1oc.Y4>^Lidt 6Qo2T7 Phone Z4 y 7Iocb <br /> GIS Coordinates:X ,Y ,Township k� Range t0 / _ Section Z / <br /> WORK TO BE PERFORMED <br /> )(NEW WELL/BORING(CPT,GEr810RING# <br /> DROPUNCH, HAND-�UGER, HER-) p DESTRUCTION(choose type below) <br /> baso 0 OVER-BORE <br /> ,'�W 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 4OLLOW STEM DIA. OF BOREHOLE 04 MULTIPLE CASINGS?0 YES JR\Q0 WELL CASING DIA: 2l,, / <br /> 0 EXTRACTION '0`AIR HAMMER/DRIVEN CASING THICKNESSSA cP/fv)a 4u TYPE OF CASING: 0 STEEL /�q\p VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL EE TREMIE TYPE TO BE USED: UGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes jj,,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH SS F4i 1 ,$;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? tar a ( if YES, list specifications here): <br /> D <br /> COMMENTS: 55 �- tJRPAovUD woarTDA?CV) OE(EenISEA I <br /> 09111 <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 /> J-IE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x j Title PAoject (;7ZL CI )7Date 2-0-) <br /> � 7 <br /> SEE SITE MAP N UNIT IV WORK PLAN DATED: LXC- e rvtAe,­ 2, 19g1 <br /> DEPARTMENT USE ONLY ,r l — L'cit-oc� <br /> Application Accepted By Date Issued � �� O Area 0(g� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 04W-4" 23099 <br /> 2,3100 23 01 <br /> "DE <br /> Y: AID# <br /> PECOINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST X INVOICE <br /> 1W 13 8 A-/ boz 0 9 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />