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WEL`--PERMIT APPLICATION SRM UNIT IV <br /> SAI`4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 Tale.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �2s�— il"� nom/_ Assessors <br /> WELL Location Z ` nnlq-o W Cross Street ity Zip 7J• P t# <br /> PROPERTY Owner� Addressao A—*e_, 774 P Phonneo661%973—?206 <br /> C-57 Cont raaorJM (syb Address/ 7�L/L -&&JM A 4t4Y PRM—FUC*AQRrt�hone#7 -7 1dV� <br /> Consultant I Sub Contractor`i7[_��•L�1�_fAC Addre `�ih' 76=14,LiG✓"��P�ne#3& ~Z�Z <br /> GIS Coordinates:X Y Township CRat Section <br /> WORK TO BE PERFORMED <br /> dEW WELL I BORING(CPT.GEOPROBE.HYDROPUNCH, HAND-AUGER.OTHER-) Q DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE10 MULTIPLE CASINGS?0 YES f"NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER(DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL g-PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IS 1 TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH -42,9> p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> !]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 Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this pennit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." 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 Califomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title <br /> � l'I�`��� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> ��//��,• gmd, <br /> USE ONLY <br /> I( 4 <br /> Application Accepted By, _ md, Date Issued ��-�) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IV-5/99/MI <br />