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N r <br /> WELL I RMIT APPLICATION FOL�l 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 /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �/ c Assessor's <br /> WELL Location 0 fl-�I��L+ 1 i�l/�� ,�iE Cross Street x 7 City �G� Zip Parcel# <br /> PROPERTY Owner©u,K. 7?�� t"�tCl�[� 4_Address r, • City � Ow Zip �Phone# D 0� <br /> 1u �,1 4rADV*L. C-SII! <br /> C-57 Contractor f r d.Address! (tL,�1,t(c V" Ci NL" / Zip�Lic#ILfo(tPhone#lgl�o� V-43SO3 <br /> ConsultantlSubContractorl'tt7�it�1n6Y;' QkW# '7 4ess 1 $kf A" City[: Lic#$.G.S� Phone#C4!{�¢3��Zif��D <br /> a,r sway c s S <br /> GIS Coordinates:X Y Township Range_ � Section_ <br /> WORK TO BE PERFORMED <br /> )(NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HA D-AUG R,OTHER`) a DESTRUCTION(choose type below) <br /> j4OIL BORING# W%46G4 4 OVER-BORE <br /> WELL# P a PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORINGHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A- TYPE OF CASING: a S ET EL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS CHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-PALL DEPTH IS 301) <br /> )SOIL BORING 11 HAND AUGER APPROX. BORING DEPTH CSO p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> a OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? r46 (if YES,list specifications here): <br /> COMMENTS: l SAp qrovAA_o�v—,- eatle4 w LA Wdl.ka V- <br /> uw �s • <br /> •1 cQL_.e^ <br /> NO E: 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: "i certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of CaGfomra." <br /> -.r � - �------- --�,--rte...-.._�.---_---�-a <br /> THS APFLICANT,I 'FZAC 48 WORKENG'MftS�>.�WADV-ANrCE_-?F+OR:/ALL REQEfIRED INSPECTIONS: <br /> Signed x QJ( TN r• �• Mf�"'�"IebCwfGlS 11'�Ol�btfl�r5� Date Z Ito) - <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 5t�'�e Xg a4�&v --Aj <br /> DEPARTMENT USE ONLY <br /> Application Accepted By lu. Date Issued 3 C' ,Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> A <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY I DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S <br /> 73 10 i 1wxy- I SR# 00o2 j <br /> C-57 L CEI SLD,CON'TRA�CTOR NIUST�S GN LICE SE'&WOn-A,,M o r�wNSknwa „ DEG e.ARA 01 <br /> UNIT IV-6/23/99/sign bkpg/MI _ <br />