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WELL' 'ERMIT APPLICATION PSRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES URIGINAL <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 0N. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ;;�160r <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 /> , _ .{ /_ Assessor's 7 <br /> WELL Location 7�i�l�t 645f M9LIH sffta 1 Cross Street D City C�te'vt,_JZip Parcel# �7"'l(pO'OZ <br /> PROPERTY Ownb7 8 4!Z f Address �• p A City G 7� Zip hone# !� <br /> C-57Contractor v`��4' �"v 51 `4+ t Address 'GAG-t1 W*We- K J _City M46WJJZip�)Lic# CWPhone#�lZil�i�go0 <br /> `�' ( p 1 C.G.0 <br /> Consultant/Sub Contractor V AddressT,01(GbUt FOa4le:(1 >ffb{ -it j Lic# 30-7' Phone#.C%9)Q3q-21'10 <br /> �- ► 6 5 <br /> GIS Coordinates:X 'Y Township (y Range �i Section <br /> WORK TO BE PERFORMED <br /> R3�4lEW WELL/BORING(CP ,GEOPROBE, YDROPUNC HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> T _ S&OIL BORING V' 0 OVER-BORE <br /> 0 WELL# p PRESSURE GROUT <br /> "Other: <br /> COMMENTS: ,Q &,e. <br /> TYPE OF WELL INSTALLATION TYPE CONSTROCTIO44 SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ^'Z MULTIPLE CASINGS?0 YES%314tLO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS PS47K� TYPE OF CASING: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�D�p­�TREMIE TYPE TO BE USED: 0 AUGERS '�-IOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:;4es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER APPROX. BORING DEPTHJ40 "Ixia / rl 9n1 TCI1 TD ACGI! r+/w or f1 CTl1\/C 121DC <br /> 0 OTHER: 1%�atTHER CONDUCTOR CASING PROPOSED?k_(if YES,list specifications here): <br /> COMMENTS: <br /> - l <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 /> 1,T4E APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x AV uiktty6oitIe R6 Date (7-5 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By Date Issued lO-l " y Areael!:9(f <br /> Grout Inspection By Date Final Inspection <br /> lB Date <br /> Destruction Inspection By Date <br /> v � F a <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 of i 5 ? SR# 00.3/3 <br /> C-57 INCENSED CONTRACTOR MUST-SIGN LICE14SE&WORKERS'COMPENSATION DECLARA'I'IrON <br /> UNIT IV-6/23/99/sign bkpg/MI <br />