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WELLPERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (} �� <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") V <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 FILE C OP 1 <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, apter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> G.5, N. <br /> o Assessors <br /> WELL Location v"`.)o N. Cross Street /Aclflc city TToctcro,v Zip 9520 Parcel# 69i-`II-33 <br /> [I�L a/o /e'TONM(rM <br /> PROPERTY Owner r,—; 4AY.RF A44r. . �~ Address 37'f Zweet" &%Tf� City rror*rwy Zip 9S26>z Phone#2o9 y-tB--LZ—eV <br /> /� i <br /> C-57 Contractor SECTRvey [Y,0-0 iI Address ZJtr GJlit/✓.a.n PA, City j22Lt2+V Zip 95zofLic#ft2284 Phone#Z09 $1547? z <br /> Consultant/Sub Contractor,/,Q% Lf✓,—E rqz exF Address /9to A~Ort&4. /Z7V14City fin, I lcL ic# N A Phone#fro 6fz-'/Tr0 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> �OEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# SVA-old ro SUE-63/. " ISr ur-ts)� I✓*w'a#, To Sumw-D206'"'�J}a PRESSURE GROUT <br /> 'Other: f✓wtwE dw . r✓wtwA-6D2�,, rue n?% SuF-oar <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING \4rFiOLLOW STEM DIA.OF BOREHOLE. /Z" MULTIPLE CASINGS?0 YES)�INO WELL CASING DIA: YN <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS .f-CN '/0 TYPE OF CASING: D STEEL PVC 0 OTHER: <br /> 'VAPOR D MUD ROTARY DEPTH OF GROUT SEAL L/ TREMIE TYPE TO BE USED: D AUGERS �ffOSF�IPJR <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:Xyes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 3d / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? (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." Contractors 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 /> WORKMAN'S COMPENSATION Laws of California." <br /> THE APPLICANT MUST//CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed !� � Foy Ae A?ta rxloa./ Title _f;2-,eAryfrr AW. Date 6/ly/99 <br /> COMPLETED <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued / Area D <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Yk4xC-fk <br /> -GOT £ <br /> vi <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED7 CHECK#/CASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> 2Ro <br /> UNIT IV- 5/99/MI <br />