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✓l,Na7 WELPPERIMIT APPLICATION F M UNIT IV <br /> j ✓uJP <br /> 5�5P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEA LTH DIVISION (PHS-EHD) <br /> 304 E. Weber,'Third;Floor; Stockton, CA., 95202 <br /> (209) 468-3449 . ED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit'ito 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 /> .r�� II r� I Assessor's <br /> WELL Location 9-A86- 6, r✓S4 mo,4,54-Cross Street G T City-ov1 Zip Parcel# <br /> .Nsen 10 <br /> PROPERTY Owner 111110",��) l/�.0 � � <br /> Address' • � �O�C ICity. IgaNb45 Zip���^phone# O 500 <br /> C-57Contractor V+yJ Ua Y�lt\vtAddress ��. Box 5' I City IOV1w4Azip5457I_ic#7Z0504Phone# ;�f 3 15 <br /> f}-- boll csoLdeh 'Foo loft El Doygdo VIL-G C-41le-) p <br /> Consultant/Sub Contractor @izn„ ejJ 0 Address - u'r City kII/s Lic# Phone# !/ -A 1740 I` <br /> GIS Coordinates:X Y ,Township l Range. Section <br /> WORK TO BE PERFORMED <br /> i <br /> Vg NEW WELL/BORING(CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER-) a DESTRUCTION(choosetype below) <br /> % 0 SOIL BORING# 4 - -- 0 OVER-BORE <br /> 'Other: <br /> tQ'%ELL# MW-I, M I.t)-� /l l w -•3 0 PRESSURE GROUT <br /> '' <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING O(HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?a YES a NO WELL CASING DIA: oZ rr <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 5ct% 4a TYPE OF CASING: a STEEL WVC a OTHER: r <br /> a VAPOR a MUD ROTARY DEPTH I OF GROUT SEAL - TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Vies a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER APPROX. BORING DEPTH J~-S V(OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER: _ 0 OTHER CONDUCTOR CASING PROPOSED? <br /> (if YES, list specifications here): f <br /> 4 <br /> COMMENTS: - 'I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS f` <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." Contractors 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 APPMUST CALL 48,W RKING HRS IN ADVANCEFOR ALLyREQUIRED INSPECTIONS. <br /> Signed l Title %I:A l GCD(Oat Date III <br /> SEE SITE ap IN UNIT IV 'WORK PLAN DATED: to I0Z 99 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued !��((��[ / Area <br /> Grout Inspection By. Date Final Inspection By <br /> Destruction Inspection By bate <br /> COMMENTS.I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 7trsr/ 9qw <br /> C'-57I,lCENSED CONTRAC'TOk4VWST SIGN LICENSE& ORKERS COIVIPEI SAIION,DECLARATION <br /> UNIT IV-^6'/2'3/99/sign bkpg/MIS <br />