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06-15-1999 01:36F'M Fir-`N T6 15102333204 P.03 1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third door, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDAISLI~PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Courcy for a permit to construct andlor install the work described. This appfcation is made in compliance with <br /> San Joaquin Cou6W Development Title,Chapter 9.1115.3 and:the Standards of San Joaquin County.Pub6c.Health Services,Environmental Health.Division. <br /> �j Assassor'V <br /> WELL location la YQ P.f`I/ .E7r Toss Street City dip Parcel# <br /> PROPf=RTY Owner i A Cr+<s5 Y /,tom iry /� Twp Phone# <br /> C-57 Contractor / Address/ Q�he City ids^ ip th $?Pfiortex��� <br /> Consultent l Sub Coniractar // . / dre2&42 L/%L,,4-%//f(�f2y City i' / Phonef� � ( <br /> .rL-1, <br /> � "�."". <br /> Gt5 Coortlinates:X__37°5,/'d•Sf�' Y /�i"/6 1,41b-la Township Range Section <br /> WORK TO BE PERFORMED <br /> &/"WELL I BORING(CPTEOPROB HYDROPUNCH.HAND.AUGER.OTHER") o DESTRUCTION(choose type belowi <br /> IL 4RING#,--:�7 _ r fl OVER-GORE <br /> 0 WELL= I3 PRESSURE GROUT <br /> 'Other: <br /> COMMEN'T'S: <br /> ;'RPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING O',HOLLOW STEM -OLk Or BOREHO c / MULTIPLE CASWGS?Q YES &4 WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHEFt <br /> :G VAPOR . 9 MUD ROTARY DEPTH OF,5ROUT SEA_ 7I REMIE TYKE TO BE USED: D AUGErZS QI-I.OSE <br /> (]At SPARGE' �SH POINT' dROL7 SEAL PUMPED: 0 Yes a Na (NOTE;MAXIMUM FREE'-FALL DEPTH IS 30') <br /> Zi <br /> IL BORING a HAND AUGER APPROX- BORING DERTH �. I [I BOLTED TRAFFIC BOX or U STOVE PIPE <br /> Q OTHER' CONDUCTOR CA5iNG PROPOSED?_AL_{i;YES.NGt spacir=ions here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR.ENCROACHMENT.PERMIT'S4 <br /> i hereby certify that I have preparecl this application and that me work will be cone in amornance with San J=On County Ord'nances,State Laws,ano IRuies <br /> and Regulations of the San Joaquin County_ Hcrneowrw or fsoensed agent's signature certifies the following. "f cefVfy that in fhe performance of the work <br /> for which this permit is i=uad,I shall not employ persons subject to WOF;<KAAWS COMPENSA77ON Lawes of California." Contractor's hidng or sub- <br /> contracting signature certifies the following: `I certify thsr in the performance Of Me wont for whAV?this permit is issued, I shall employ persons subXj cr to <br /> WORKMAN'S COMPENSAr10N Laws of California,' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signore x Title Owe <br /> SEE S TE MAP' IN,, UNIT IV WORK PLAN. DATED <br /> By <br /> 14 OF"PARTMENT USE ONLY Bata Issued <br /> v C <br /> ApAfaCation ACCeptea 6 Area ` <br /> Grout Inspection By Date Final Inspection Sy Date <br /> Destruction Inspection By bate <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACIk <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK#1CASH RECrqw BY DATE PEFtMIT/SERVICE REQUEST NUMBER INVOICE <br /> UN17IV- 5199/Mr <br />