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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) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor 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 /> CE M E Y E RIf Assessors <br /> ELI-Location NAR 0 t K G WAJ Cross Street LAN City 5 TGC(%TO N Zip 9520 l Parcel# <br /> SRN -ToAp,VtN (Z09) <br /> PROPERTY Owner CAIR0LIt- CE ME CERY __Address Poli 1131 City STOQCT4N Zip 95ZOI phone# 66-6207. <br /> G. R11CrIr MftATiN[f 54553 656401 0ZS) <br /> 57 Contractor bi11LItA(, b1EST1N6-Address 9 S 0 H0WE RVAD City Zip Licit Phone# 313- 5000 <br /> iRANCIA0 R.U. I916 <br /> Consultant/Sub Contractor ISA M A G 1= E NY Address Pal 660 Cdy tW P,t I-TA Lie# S 6 Phone# <br /> FS Coordinates Y Y Township Range- Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CP GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) I7 DESTRUCTION(choose type below) <br /> J SOIL BORING# C T-l A 'Z 3 '# G OVER-BORE <br /> p WELL# PRESSURE GROUT <br /> 'Other <br /> OMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA OF BOREHOLE Z-_tt4 MULTIPLE CASINGS?a YES I NO WELL CASING DIA NA <br /> TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS H A TYPE OF CASING a STEEL Q PVC p OTHER N A <br /> OR o MUD ROTARY DEPTH OF GROUT SEAL T 4"r 16O r TREMIE TYPE TO BE USED []AUGERS /HOSE <br /> 0 AIR SPARGE I PUSH POINT(C rT) GROUT SEAL PUMPED p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1 SOIL BORING []HAND AUGER APPROX BORING DEPTH I r.4 r p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED? W) (d YES,list specifications here) N A <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 agents signature certifies the following `7 certify that in the performance of the work <br /> for which thrs permit is Issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Cahfomia" Cont,aclor 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 /> WORKMA S PENSATIOia Laws of Cahfomia" <br /> E APPLICANT MUST CAL 48 HRS IN ADVANCE FOR ALL REQUIRED INSt'ECTIONS <br /> Signed <br /> Title Date VJ I <br /> 'SEE SITE MA IN UNIT IV WORK PLA DATED G 120 101 <br /> DEPARTMENT USE ONLY / <br /> pptitaUon Accepted By <br /> Date Issued YI ��z- Area <br /> Grout Inspection 8y Date Final Inspection By Date <br /> Destruction inspection By Dale <br /> COMMENTS I CONDITIONS <br /> FAC# <br /> rP�E <br /> NT[NG ONLY AID# <br /> DES FEE INFO AMOUNT REMITTED CHECKICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE! 1./f oZR# 00? s� <br /> UNIT IV-6/1/99/sign bkpg/MI <br />