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WEL,. PERMIT APPLICATION I0RM 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 /> 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 /> c- Assessor's <br /> WELL Location )Cross Street /H City 542-L-le— Zip Parcel# <br /> 09 N 967-402 ir <br /> PROPERTY Owner Ike A55 e/ti.t+u�slble �,wSfAddress 1?025 N. I.JCSf 1,7. City 5/-040— ZipCif _Phone# '76-2 f0 <br /> C-57 Contractor Q1"r%ex ,fir,c. Address II,,nn //City�✓Ar d Zip CALic#�Phone#(s/0).Zfi6 -�66 <br /> Consultant/Sub Contractor I/LPAc(we(( 5 kel[ t� Address 5SS fi 2,,— C ty F Lic# Phone# 4/S �!✓rS-90 0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) O DESTRUCTION(choose type below) <br /> `SOIL BORING OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2 f MULTIPLE CASINGS?0 YES*NO WELL CASING DIA. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEAL f TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED O Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER APPROX. BORING DEPTH O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: BOTHER INktA 04�ONDUCTOR CASING PROPOSEDI (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 "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSAT70N Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: 7 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 APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x / -� G Title S rrri 6e1P10%15,1 Date <br /> SEE SITE MAP 14 UNIT IV WORK PLAN DATED: <br /> f � DEPARTMENT USE ONLY <br /> Application Accepted By C�, G 263 Date Issued C� 7 ( ( Area J`/ <br /> Grout Inspection By -Date_V4 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'9/13Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o i 8 6 11 "qSEW OZ 2-5 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICES ORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> Z 'd vloO :id VIdZS:V 6661—L I—I I <br />