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CATION F.URM UNIT N <br /> WELL PER APPLI _ <br /> -, ,'SAN'JCSAQUIN COUNTY PUBLIC HEA TH SERVICES <br /> JUL <br /> R47NMENTAL HEALTH DIVISION (PHS-EHD) <br /> 013 ' - eber, Third Floor, Stockton!I CA.,195202 <br /> (209) 468-3449 <br /> I , <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 /> t San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, EnwrAssesstor's Health Division. <br /> r It�r) Zip l# <br /> 4 i d Do Cross Street t City f P fParce <br /> WELL Location F <br /> /�! ! <br /> �pral�lolNr_ f o P�`�i e _AddressPhone v <br /> ._Qf�� t3fi S1A� 1� City f�4��a Zip <br /> PROPERTY Ownerlr <br /> Phone# f <br /> j� r]���Lic# .�3 Z t t 7 'Ir)X, <br /> C-67 Cantraofor Address �! LAS City-5�f1-?gip ` <br /> { f i] <br /> c j, ' Address, Al (,vtfSDir( ity&�Lic# `r7 Z Phone c1 ' /��(� <br /> # Consultant 1 Sub Contractorf{{ <br /> Y Township Range Section <br /> GIS Coordinates:X Ij <br /> WORK To BE PERFORMED <br /> EW WELL 1 BORING(CPT,G OPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 1' p DESTRUCTION(choose type below) <br /> L OIL BORING#, OVER BORE <br /> # PRESSURE GROUT <br /> a WELL , <br /> 'Other: Ii <br /> COMMENTS: Ij <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA. OF BOREHOLE " MULTIIPLE CASINGS?0 YES - X10 WELL CASING DIA w- <br /> iAl <br /> EXTRACTION [j AIR HAMMER/DRIVEN <br /> CASING THICKNESS YPE OF CASING: d STEEL 0 PVC OTHER: <br /> o VAPOR I)MUD ROTARY DEPTH OF GROUT SEAL ire TREMIE TYPE TO BE USED: p AUGERS_ VOSE <br /> { p AIR SPARGE GUSH POINT GROUT SEAL PUMPED: D Yes 1Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I <br /> 1SOiL BORING HAND AUGER APPROX. BORING DEPTH �yD.� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> j] CONDUCTOR CASING PROPOSED?_ { if YES, list specifications here): <br /> OTHER: OTHER <br /> ! ' <br /> COMMENTS: 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws&a &,TRk1:ft <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifiesIthe following: "l certify that in the performance ork <br /> for which this permit is issued, t shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hirincontracting signature certifies the following: "I certify that in the performance of the work for whi4h this permit is issued, 1 shall employ persons su <br /> WORKERS'COMPENSATION Laws of California." <br /> CA L THE UNIT IV INSPECTOR 48 WORKING IRS IN ADVANCE FOR ALL REQUIRED INSPECTIO ^: <br /> Signed x ✓� TitIe/Company �� ��}U+ �I <br /> �`Y�y, iI 1�nAn Date I. 1� 7 -0 <br /> Print Name t,e, <br /> SEE SITE MAP IN UNIT !V WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> 1I <br /> Appticabon Accepted By 1/� 1/t no^—� _ Date Issued I7 3 Area <br /> Date t Final Inspection'!By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date I! <br /> COMMENTS l CONDITIONS: !� ' <br /> ACCOUNTING ONLY: AID# i 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> oaa.33ss <br /> 1/18/2000 <br />