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1-28-2000 8 : 1 8AM FROM P. 3 <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) ORIGINAL <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 />Assessor's <br />WELL Location \1�1�?i+l Cross Street l21 ST Ci:y zip9�3�6 Parcel# 1,1L'j.rl0'`00 <br />PROPERTY Owner3A,.,7N,JLeu r,Wll Address 1011AD Blvd City L_ A ZipJ002 Phone# 3 I O Lob IYw <br />C-57 Contractor Y rcA e. Address LaiL-L rl ST CityAllll fci ZipgJ,4-Li " o Phone# <br />Consultant/ Sub Contractor(aeo_G_V- _IASLIA Address 317.6Kyri IS 11 7- City 4 i�L1M# Phone#$20 ?S4 Sfaifo <br />GIS Coordinates: <br />Townsh <br />WORK TO BE PERFORMED <br />�N�1FFi�fC-EL / ORIN (CPT,GOROBHYORQPUNCH, HAND -AUGER, OTHER") <br />O <br />{ <br />ELL # <br />"Other: <br />COMMENTS: <br />Range Section <br />p DESTRUCTION (choose type below) <br />U OVER -BORE <br />U PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE I %' MULTIPLE CASINGS? 0 YES MNO WELL CASING DIA: <br />U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER; <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: d AUGERS OHOSE <br />0 AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: 0 Yes ifNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />`SOIL BORING U HAND AUGER APPROX. BORING DEPTH �Q t p BOLTED TRAFFIC BOX or U STOVE PIPE <br />0 OTHER: 1 OTHER CONDUCTOR CASING PROPOSED? (( II (if YES. list Specifications here); <br />COMMENTS, l \ I or l �,A 2' �bc_f V1ScS �Q1�'� <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, 1 shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the f wi g: 'I certify that in the performance of the work for which this permit is issued, f shell emptoy persons subject to <br />WORKEi2S' COMPENSA N .. California." <br />ALL HE U �NSPECTIOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed xTitle/Company 111-A1t�r4• /(J« /�� cruC <br />Print Name <br />SEE SI P IIVNIT IV WORK PLAN' DATED1. <br />DEPARTMENT USE ONLY <br />Application Accepted By. Uize4�Date Issued O O Areaa! <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />II PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # I RECD BY I DATE I P / SERV`ffrREeWZST # I INVOICE <br />MIiM�Im <br />