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WELLQ,'ERMIT APPLICATION FSM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE COPY <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 andior install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's `' <br /> WELL Location `1! Cross Street i City G L Zip Parcel# 1-57 -Z44-2,2- <br /> -2.z <br /> PROPERTY Owner M&ik5 Address_ 4Wh ` Cit ,; W i Phone# d S Do <br /> Y P��f53A <br /> C-57 ContractorLa 41l , ddress 1SA�Q �SLL City Af a zipgY553 Lic# WPhone#lgli"+!X_5 qo <br /> Consultant/Sub Contractor{ {.- h V1,�4K KhP.�AddresQ1(6t)We-lE1D>Lu1t l Cit &_96,_!j"hone#Cq Q i Iq"Z <br /> GIS Coordinates:X Y_ Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> II SOIL BORING# 0 OVER-BORE <br /> )J�tVELL#� - PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF V16C-L� INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IONITORILttc! OLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?a YES JfNO WELL CASING DIA: Zt? <br /> /p EXTRACTI [V'D AIR HAMMER/DRIVEN CASING THIGKNESSe 0_TYPE OF CASING: 0 STEEL M�VC Q OTHER; <br /> a VAPOR 3C 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> a AIR SPAT r N 0 PUSH POINT GROUT SEAL PUMPED: Xes a No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> SOIL 80 _ <br /> LJ T []HAND AUGER APPROX.BORING DEPTH __ BOLTED TRAFFIC BOX or STOVE PIPE <br /> 13 OTHER: +Ll- 0 OTHER CONDUCTOR CASING PROPOSED? JJO (if YES, list specifications here): <br /> CC rs <br /> COMMEN <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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: 'Y certify that in the performance of the work <br /> for which this permit is issued,f shall not employ persons subject to WORKERS'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 /> WORKERS'COMPENSATION Laws of California." <br /> N.";` + Ci4MT MLdST C L4'8 0"FtKtNr, HRS."E xADL�AN.CE ALf_R_QU1_KI=D N_SP GTlON�S.. <br /> Signed x Ti#ler �fs j �a?i D Date_-c9_� 1 I lJ 1 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: z �� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By f i f Date Issued 4� -24 a3 Area s`� <br /> Grout Inspection By " Date Final Inspection fay ate �3 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: r u n - r;n <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l�3SR# d4 3 + 321 <br /> CDwbUT <br /> MRM <br /> '� 0 � ICES �jRC?1VI1'�EA�' `IODEC ? 0 <br /> UNIT IV-6/23/99/sign bkpg/MI <br />