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WELL PERMIT APPLICATION FCiM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N �� �J E <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 FEB 1 8 2003 <br /> (209) 468-3460 <br /> ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PFRMIT�SF1�� F <br /> Application is hereby made to San Joaquin County for a permit to construct andior install the work described. This application is made m o 1 th <br /> San Joaquin County Deveiopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> WELL Location A ® / c�: ross Street Z t� City C. ip Parcel# <br /> PROPERTY Owner��l�+ - �� � Address c City Zip 3 [[Phone# ? -'��l)O_K 712- <br /> C-57 Contractor— E Address <br /> �f�� CityZipLic#�z �yPhone#f>/i- 77 -�f/�7c� <br /> Consultant 1 Sub Contfactor dre�is �9C5`) ei Cit Lic# Phone# 62 2 61 � <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPR08E, HYDROPUNCH, HAND-AUGER, OTHER-) _ DESTRUCTION(choose type below) <br /> 4 SOIL BORING# Q OVER-BORE <br /> WELL# "-ARESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS �(] <br /> a MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?BYES G NO WELL CASING DIA: <br /> �]EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC Q OTHER: <br /> 0 VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS CHOSE T1 <br /> 4 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes d No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> [j SOIL BORING a HAND AUGER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or t Q STOVE PIPE <br /> {]OTHER: CONDUCTOR CASING PROPOSED? (if YES, list specifications Here): <br /> COMMENTS: <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: "t certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S 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, 1 shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California." <br /> AP_LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. <br /> Signed x Title 4===Qate ;2 l2 <br /> SEE SITE MAP SIV UNIT IV WORK PLAN. DATED ,2--9 -03 <br /> D PARTMEN7 USE ONLY <br /> Application Accepted By �ti Date Issued �( Area <br /> Grout Inspection By Date U Final Inspection By ate_ �� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDI IONS: /'o ( � <br /> FAC# <br /> ACCOUNTING ONLY: A& <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK91 SH RE lV DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3 0 S <br /> CS,SCENEDICONT „CTOR 11!MLSSGIIC . C�II?EASATT®bDEG O1 TIONS <br /> UNIT IV- 6/18/99 /sign bkog/Wi <br />