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8-12-1999 10 03AM FROM P 3 <br /> WELL PERMIT APPLICATION FORM 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 />[ELI-Locabonn Joaquin County—Development Title Chapter 9.1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> SIPS,R �U�K- 04'0,i_o Cross Street ty 2ip SZO r Assessors <br /> �Lbt�'TO nl Parcelt! <br /> H O;F�MAiJ Z5 <br /> PROPERTYOwner �oi R[J�1�pests rc,Addres W-. R City E�sr�t;�s Zip(ged,79 Phone# Z <br />�-57 Contractor �1P�nJ X <br /> Address _2Z7402- Foi.EY JT. City!-IAYtJAr'DZipy°f5`fSLio#7D5�IZ7 Phan ��✓4 Z6�c? <br /> Consultan Sub Contractor T► Address po+'z'l!-+AAr H <br /> Clty CVNW­01rs7 Lic# Phone# <br /> FIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING{CPT HYDROPUNCH HAND-AUGER, OTHER-) III DESTRUCTION(choose type below) <br /> SOIL BORING# ✓A-l,VA4&� VA`lfJ VA"S7, VA-VA-(, p OVER-BORE <br /> [�WELL# a PRESSURE GROUT <br /> 'Other <br /> WOMMENTS <br /> PE OF WELL IN$TALLATION TYPE CON§TRUCTION SPECIFICATIONS <br /> U MONITORING a HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?p YES I NO WELL CASING DIA <br /> RACTION AIR HAMMERIDRIVEN CASING THICKNESS_ A TYPE OF CASING 0 STEEL a PVC ,OTHER <br /> WNWOR MUD ROTARY DEPTH OF GROUT SEAL IL r=a bs TREMIE TYPE TO BE USED d AUGERS OHOSE <br /> a AIR SPARGE PUSH P01NT(t>V7) GROUT SEAL PUMPED III Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER APPROX BORING DEPTH i L- FEE[" a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> OTHER p OTHER CONDUCTOR CASING PROPOSED? J'J (If YES list specifications here) <br /> COMMENTS C?rZ1tJG,S WIC—t— 6C7 ViIz4L4-Z_'V. M — tii l7 T IDOAi <br /> R U dMi2+`3 QF [ti C L C.�Q r IJ Snt rdTAc� RaR.+nrG�W)C..L_Sr_ 17121 t ten. <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> nd Regulations of the San Joaquin County Homeowner or licensed agents signature certifies the following "l certify that in the performance of the work <br /> r which this permit is issued 1 shall not employ persons subject to WORKERS COMPENSATION Laws of California" Contractor's hiring or Sub <br /> ontractmg signature certifies the following 1 certify that in the performance of the work for which this permit is issued I shall employ persons Subject to <br /> WORKERS COMPENSATION Laws of Caldomrs - <br /> THE APPLICANt MUST CA1L 484ORKING HR$ IN ADVANCE.FOR ALL REQUIRED INSPECTIONS <br /> ignad x �o fti- Jct <br /> r7J3 Tlge I -�Xsc,. �1i PJiv.oa�s Date <br /> SEE SITE MAP UNIT IV WORK PLAN DATED ro /2!:!rIg9 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> rout Inspection By Date Final Inspectron By Date <br /> estruction Inspection By Date <br /> COMMENTS i GONDiTiOnS <br /> OUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTirD CHECK di RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> FCT <br /> -57 LICENSED CONTRACTOR MV. T' SIGN LICENSE &WORKEAS' COMPENSATION DECLARATION <br /> IV-6/23/99/sign bkpg/MI <br />