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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> :_It�F��`'613s1'I�CF ¢Al_l!I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> : 4I ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> PM I <br /> 02 FEB -I 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Environmental Health Division. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is Assessor's ade in PIG'l`I with <br /> �• M,"zf $t°cl.�a.n zip Q52o2 Parcel#�vr ps <br /> San Joaquin Co Sty Dle de to <br /> an Joa Cwt Chapter 9-11 <br /> 3 and the Standards of San Joaquin County Public Health Services, <br /> de Cross Street A._y 5�• City�— <br /> M`^ar QSZrR Phone#�43�-84e1 <br /> WELL Location Sid ( 60'D E' S�c�.4�++ ZiP <br /> 1. ogock�f Address �I25 N• ClQecddoSk.ciry�� 7oT-g7�-`!gam <br /> PROPERTYOwner Citl`�r°ytsj_ Zip9'�S7l Lic#ltas7 Phone# -- <br /> Iw�_...�.. QCt11tv�,_Address Po BoK 336 y 72t1 Phone#91b.6 <br /> C-57 Contractor <br /> Deas City��' <br /> Consultant/Sub Contractors--r Ranger Section <br /> GIS Coordinates:X�--=Y�� <br /> Township___ � <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> OVER-BORE <br /> *NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 PRESSURE GROUT <br /> O SOIL BORING# ,6�/}�$ C� <br /> WELL# '"' 2 S <br /> -Other: a g 4 <br /> COMMENTS: CONSTRUCTION SPECIFICATIONS O WELL CASING DIA:2 �Y <br /> TYPE�E�L INSTALS MULTIPLE CASINGS? : YES EL <br /> HOLLOW STEM DIA.OF BOREHOLE a�� <br /> ,gMONITORING I� �TYPE OF CASING: Q STEELVC OTHER: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5 <br /> p MUD ROTARY DEPTH OF GROUT SEAL Sig TREMIE TYPE TO BE USED: Q AUGERS OSE <br /> 11 VAPOR GROUT SEAL PUMPED:gYes H No (NOTE: MAXIMUM FREE-FALL DEPTHSTOVE PIPE <br /> O'' <br /> �'AFR SPARGE 02aN 6 17 PUSH POINT IID 12Q�BOLTED TRAFFIC BOX or 0 <br /> HAND AUGER APPROX.BORING DEPTH �Q 6 <br /> 0 SOIL BORING if YES,list specifications here):�- <br /> 0 OTHER— CONDUCTOR CASING PROPOSED? NO <br /> a OTHER:— <br /> ( %12D W �� e 1 ke l03 Sir cn <br /> COMMENTS 0 r� o 401 65r IIo �� 5 <br /> J <br /> UIRE ACCE S OR ENCROACHMENT PERMI and Rules <br /> OTE: OFFSITE BORINGS REQ 9 o that rd the performance of the work <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count t in the s persons subject e <br /> persons sub'act to WORKERS'COMPENSAT'10 N Laws of Calrlfshall emContractor's r hiring subject <br /> sub- <br /> and Regulations a the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I cernto <br /> for which this permit is issued,1 shall not employ P <br /> contracting signature certifies the following' I certify that in the performance of the <br /> work for which this ennit is issue , <br /> WORKERS'COMPENSATION Laws of California." <br /> TuC AP ICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> y�y yr r�I / < r L7CA'o9ts� Date <br /> / � S/// v) Title <br /> Signed x 11 2 7 0 1 _�— <br /> SEE SITE MAP IN UNIT IV WORDEPARTM NPLAN <br /> oNY DATED: _-- Area `� Y <br /> Date Issued �' Date a d3 <br /> Application Accepted By Y Final Inspection By <br /> -, Date- <br /> �. -�-- , <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> OC <br /> ACCOUNTING ONLY: AID# RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOU T R MITTED CHECK# �� <br /> ase5 Sgs 5 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLA�TION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />