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WELL PERMIT APPLICATION F M UNIT IV <br /> r. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES QFr— eo- /Cbl <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS <br /> 304 E. Weber, Third Floor, Stockton, CA., 9 ffft Copy <br /> oPY &-'A <br /> (209) 468-3450 PR=** <br /> `Uvl LtJ• NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Countv for a permit to construct andlor install the work described. This application is made in compliance with <br /> San Joaquin County Development Title, <br /> ,Chapter 6-1111x5.3_and the Standards of San Joaquin County Public Health Services, Environmental <br /> Health Division <br /> WELL Location Wr `6 ,/r& ( -/ Cross Street 4S .c gCity Zip ay07 Parcel# '� A <br /> PROPERTY Owner��• / (J� A'ddrrelss City Zip Phone# V <br /> C-57 Contractor4�^ rix- Address agyro - �C�ity� �++ ZiP Qj?d rLic#S/��J,6 APhone#CJo9)r/65-f7/A <br /> Consultant/Sub Contractor I F/2 u(NG-�n C.tC Address(//MOR'welll /-r /2!F,�City Mill Lic#_Phone#(/01(73?'�/0�0 <br /> GIS Coordinates:X <br /> Y.,Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION (choose type below) <br /> 'NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH. HAND-AUGER,OTHER') 0 OVER-BORE <br /> 0 SOIL BORING# D PRESSURE GROUT <br /> 'WELL It ,SVS"O/3 <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING `,HOLLOW STEM DIA.OF BOREHOLE IA7 rrrr MULTIPLE CASINGS?D YES �NO WELL CASING DIA:Yrr <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS=;x . O _TYPE OF CASING 0 STEEL 'PVC 0 OTHER: <br /> `VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 r TREMIE TYPE TO BE USED: D AUGERS kOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:e2-Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 130 r BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED" 41a (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 WORKMAN'S 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, 1 shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> THE APPLICANT MUST <br /> �CALL <br /> D48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> >o Title.l�le. �Ald. r5 <br /> —Date rZ3/4 <br /> Signed x- VV <br /> Cru F�Eti <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED ///� <br /> DEPARTMENT USE ONLY 9 Areae <br /> Application Accepted By Date Issued 0 <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IV-5/99/MI I / <br />