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WEL.- PERMIT APPLICATION. JRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVE E <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 16 1999 <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 />o / / 952p� Assessor's <br />WELL Location p %6� �.iis %l Cross Street %j�of�f City71�C1 Zip <br />Parcel# <br />PROPERTY Owner �Ct' .(fle,11A1 Address%iCpli si. 1pew, 5 W City SWooltkcr#1 Zi.D�-M)? Phone# LA1$- 1614 <br />C-57 Contractor F/5 A 641V 1etMJ ,A�( Address .moi SWI RA" City�Zip Lic#�8386�i Phone# -1-12-3510 <br />Consultant/ Sub Contractor 6o-&-- J 2try Address 1114 V%N;�4 5+ City cc Lic# Phone# %3$-cl "4SI <br />GIS Coordinates: X , Y <br />Towns <br />WORK TO BE PERFORMED <br />`NEW WELL 6a3CPT, EOPROB HYDROPUNCH, HAND -AUGER, OTHER-) <br />'SOIL BORING # - I Ci <br />0 WELL # <br />Range Section <br />0 DESTRUCTION (choose type below) O <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />`Other: <br />COMMENTS: 461-n.l °b S hor +a0.5 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 UucA MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS o TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .3Oi fei TREMIE TYPE TO BE USED: GAUGERS 0116SE <br />0 AIR SPARGE GUSH POINT GROUT SEAL PUMPED: 0 Yes '0'\No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')C <br />0-90IL BORING 0 HAND AUGER APPROX. BORING DEPTH —3b. C -t 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />r <br />COMMENTS: <br />NOTE: 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 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,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ 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 />T PLICANT UST WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x ­ , Title F—�' �;-073 Date Q' 2 ;R7010 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: i- 2o -woo <br />DEPARTMENT USE ONLY <br />Application Accepted By ( t Date Issued 31 O(!:) Area <br />Grout Inspection By .= Date 11 dv Final Inspection By a+--\ Date 41 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE / SERVICE REQUEST # <br />00;t,39S) <br />INVOICE <br />5- 01 <br />,J1'39.00 <br />CLOUT <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' CONff7E1V9A'IrION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />