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-20-1999 10:00AM FROM <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAP}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 and/or install the work described. This application is made in compliance with <br /> San Joaquin county <br /> /Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environ a Sorental <br /> s Health Division. <br /> WELL Location �I7 �`I(aii3 ," re ffi Cross Street d1a a S7_ 4%r��tgY ZIP J��36 Parcetu - <br /> �/° � n <br /> PROPERTY OwnesCity�. aZPJ�ZLLPhone� Cs 6 r 9 <br /> C-57 Contractor <br /> dress_Z10City -°n ziotlC#yBSIlPhone7: /3 <br /> (� hr Etl�l r fo n.en7adress,//yf1 /e 5 T Ciry _�Phone3!��d `>'l//-309 <br /> :,onsuttart/Sub Contractor, n <br /> �7 q,( Range _ Section <br /> GIS Coordinates Xj� /3l Jay -Y —/1/,%�57� Township <br /> WORK TO BE PERFORMED <br /> �DESTRUCTION(choose type below) <br /> t`NEW WILL/BORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER? a OVER-BORE <br /> o SOIL BORING V 0 PRESSURE GROUT <br /> p WELL¢,_ <br /> 'Other. <br /> COMMENT'S: <br /> WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS MONITORING I(HOLLOW STEM DIA.OF BOREHOLE—_MULTIPuz-CASINGS?iYEs 0 NO WELL CASING DIA�_// <br /> I] <br /> �_XTRACTION p AIR IiAMMERJDRIv1=N CASING T HICKNES= R. r{n TMPS OF CASING: Q S'fEcL 0 PVC Q OTHER: <br /> 0 VAPOR ]MUD ROTARY DEPTH OF GROUT SEAL 90 TREMIE TYPE TO BE USED: f/AUGERS OHOSE <br /> 0 AIR SPARGE 0?USH POINT GROUT SEAL PUMPSD: es 0 No (NOTE:aMAXID MAXIMUM <br /> C BOX oLLDEPTH Q STOVE IS 30') <br /> 0 ST(L BORING 0 HAND AUGER APPROX.BORING DEPTH �J� QI ` <br /> CONDUCTOR CASING PROPOSED? &0 (if YES.list specifications here): <br /> D OTHER <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I nereby certiiy Ina&I nave prepared this application and that the work will be cone in accordance with San Joaquin County Ordinances.State Laws,and Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensed agents signature certifies the following: "I certify that in the perlorrnance o!rhe work <br /> for which this permit is issued.I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub, <br /> contracting signature certifies the following:'I certify mat In the performance of me work for w1)lc1l oris permit is issued.I shall employ persons subject to <br /> WORKMAN'S COMPENSA77ON Laws of Celifomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Titre r r r /an�Date 0 <br /> Signed x <br /> SEE . SITE WP IN UNIT IV WORK PLAN. DATED s Z0 p <br /> DEPARTMENT USE ONLY <br /> Date Issued /�-l Area <br /> Application Accepted By Date <br /> Grout Inspection By Oate Final InspectionBy <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC* <br /> ACCOUNTING ONLY; AID# <br /> ?E CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER ( INVOICe <br /> 0 �1 <br />