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'� ...� WELERMIT APPLICATION FARM 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 /> ii � e Assessor's <br /> WELL Location�d�j0 5�(,t,1 l,t QII 1�E 14"1-e Cross Street �. 77 C1ity TaG� �'�Zip Parcel# <br /> PROPERTY OwnerDLf t1�6f Address% � 'J-f• City wew Zipfqg <br /> Co <br /> C-57 Contractor l�ltTQp piif��i++� h6 lid+AddresslgoSA,! ti(ctresS1JYf- Ci�1 M44Zipq%ULic# qPhone# (off-3583 <br /> Consultant/Sub Contractorgoirilou yi-oykNt less 1 $K� Jr[* CityG{ Lic#"5_44 hone#(�fj& 4,""Z7 <br /> - - 6l,.' way ( 0 <br /> GIS Coordinates:X _ ,Township Range 4 Section _ <br /> WORK TO BE PERFORMED <br /> WNEW WELL i BORING(CPT,GEOPROBE,HYDROPUNCH, HA D-AUG R,OTHER*,) DESTRUCTION(choose type below) <br /> 'OIL BORING# pl,�,�e U OVER-BORE <br /> WELL# t a PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING % HOLLOW STEM DIA, OF BOREHOLE_MULTIPLE CASINGS?U YES I WELL CASING DEA: <br /> U EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NIA- TYPE OF CASING: U S ET EL 0 PVC DOTHER: NOAJ <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS UHOSE <br /> d AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes U;No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> S'kvrOIL BORING U HAND AUGER APPROX. BORING DEPTH l90 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_U OTHER CONDUCTOR CASING PROPOSED? f4O (if YES, list specifications here): <br /> COMMENTS: rt ! S 0 Y' (e 4 <br /> NO E: 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 Ordihances, State taws,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 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, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." ii <br /> _ _ _� _ D IN <br /> THE APPLICANT T CALL 48 WORKING HR5 IN ADVANCE.FORLL REQUIRESPECTIONS.A <br /> Signedx elC r r' if• itlelr�Ol4 (o Date sit2 oZ` <br /> i <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 3 12-09 J �� _ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES 1 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE'kEQUEST# INVOICE <br /> SR9o2�jf cl' <br /> G-57 t10EN9EI?'C0NTRACT0RMUST SIGN LICENSE'&WORKERS'.COMi' TSATIQN DECLARA'ITON <br /> UNIT I"- /i3/99/sign bkpg/MI <br /> '4 <br />