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WELL- PERMIT APPLICATION t -jRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 23 FtiGI&S leber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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. �f <br /> ` Assessor's 3�S <br /> ZVeCitvJTJ,� Zip Parcel# 1191-030-01,'[�h_ <br /> WELL Location Cross Street <br /> PROPERTY Owne { t V15rkctjevwlW, Zip Phone# Z .- <br /> oryo6rWW V011 � <br /> C-57 Contractor 6r�Yrs(�t"`4 _Address g519 1+'�W�rvpp` `� CityD 07�Zip 55Lic# Ib Phone#�yI513 <br /> 13L <br /> Consultant/Sub Contractorgbp zo1 544 rfl'{""( Address5O(, 60U tyOlKtll I��it�. I Lic �9 0 Phone# fi Z17Q <br /> GIS Coordinates:X Y Township Iy Range 6 fi Section <br /> WORK TO BE PERFORMED <br /> �W WELL/BORING(CPT.GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> rr vv 0 SOIL BORING# 0 OVER-BORE <br /> 0 WEL A, 0 PRESSURE GROUT <br /> 'Other: e 5 � _ I"` <br /> COMMENTS i C' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE KUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGE APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: robe 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: 3Oro -�o A. 6it0— 0 RR <br /> NOTE: OFFSITE BORINGS REQUIR ESS R ACCENCROACH ENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will b cordance 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." C <br /> T APPLICANTnMUCST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPEC-TI/ONS. <br /> Signed x = 72, 7 K�Lr'� Titlet rv✓�r bCM '�.G�t�S� Date��� / <br /> 9 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY ��j,-,/, <br /> Application Accepted By Date Issued b Area Cc <br /> Grout Inspection By Date S Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 3 SOS <br /> ACCOUNTING ONLY: AID# FACJt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Ol qt" � ` <br /> U �Ufc V pl 6D�-� 1 7 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE'&WORKERS'_COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />