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1 <br /> i <br /> WELLYERMIT APPLICATION FthtM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 0A1. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �160r <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 /> ��tt�n / -/ _ .� /� /_ Assessor's 7 <br /> WELL Location 7Lf�1.t.�,6125f Mn(IU14 Sfft9 1 Cross Street O City CK-7v�t_JZip Parcel# �?"l�'�2- <br /> PROPERTY�Owni57� �A7?:; 1 z f Address City 4w -Zihon S 4 <br /> C-57Contractor y` 5!�j )"X-fI Address 'GSCn 4�4N2Kd City Zip Lic#L C�Phone# 0D <br /> Consultant/Sub Contractor ' V+ Addressf fji(G'bUtm Foal Ot fr 4Eity5�Lic#_C 3a Phone#(*6)a�a <br /> GIS Coordinates:X 'Y Township N Range :�EE Section <br /> WORK TO BE PERFORMED <br /> W WELL/BORING (CP ,GEOPROBE, HAND-AUGER,OTHER") a DESTRUCTION(choose type below) <br /> �TTT 111 SSOIL BORINGYDROPUNC q 0 OVER-BORE <br /> a WELL# p PRESSURE GROUT <br /> *Other: <br /> COMMENTS: ,� <br /> TYPE OF WELL -' INSTALLATION TYPE CONSTR CTI SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE ^2,&1 <br /> MULTIPLE CASINGS?a YES',AO WELL CASING DIA:QM <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS VCTYPE OF CASING: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -11L-f 4p�TREMIE TYPE TO BE USED: a AUGERS -A OSE <br /> 0-/AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED:�<es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> `SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 100 "02W / <br /> /Q OTHER: THER CONDUCTOR CASING PROP <br /> 1��'bOSED? (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'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." <br /> T E APPLICANT MUST CALL 48 WORKING HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x "f Wt0 �itle Ra17 ,g'3Oa" Date_ Z O <br /> SEE SITE MAP k?'05-ONINT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued !D ! " y Area O <br /> Grout Inspection By Date 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'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3soi �Bi 5 003/3 <br /> G57 L:ICEI SED CONTRACTO�,MUST;�jt N LT�?F1 SE WdRKE1 S'`CC7 IP _ _S`A'I'ION,D CLAKAT) .�.. <br /> UNIT IV-6/23/99/sign bkpg/MI <br />