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WELL PERMIT APPLICATION I ORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SFF,`F E F <br />ENVIRONMENTAL HEALTH DIVISION (PkS H{) <br />304 E. Weber, Third Floor, Stockton, CA., 95202,_ 0 11999 <br />(209) 468-3449 {{ � r- � <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT;E�VUil9) �iyflGl`a�/'.� `,EALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/qr install the work described. b1]�fi�nl�h'piiance with <br />San Joaquin County Development Title. Chapter 9-1115.; and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />'' //'' 1 Assessor's <br />WELL Location /0 s V/0, UU � S 7� Cross Street W e 6ey, Cite`" Zip Parcel# <br />_ II i <br />PROPERTY Owner. iF.i cL e I -E Scb>4 1 m -Address pQ Fcbc SOOz City�+cY4µie-gh Zi66$S I Phone#2& b <br />C-57 Contractor Address Bopp I CityV/ Zip :� l_ic;550�1 Phone#2L6Z3-///S� <br />Consultant /Sub Contractoc,�4 S CyNlddress�city Pic <br />�ic#`x'60%%6Phone#��.�95 <br />GIS Coordinates. X Y Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL/ BORING ( CPT, GEOPROBE. HYDROPUNCH. HAND -AUGER, OTHER') <br />XSOIL BORING # <br />0 WELL # <br />"Other: <br />COMMENTS <br />TYP <br />CO <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />0 MONITORING HOLLOW STEM DIA OF BOREHOLE r�— MULTIPLE CASINGS? 0 YES $ NO WELL CASING DIA r//1' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /i/0. TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4!t1• ( TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 A R SPARGE 0 PUSH POINT GROUT SEAL PUMPED: B'Yes O No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />IrSOIL BORING 0 HAND AUGER APPROX. BORING DEPTH OO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER 0 OTHER CONDUCTOR CASING PROPOSED? Ny ( if YES, list specifications here): <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: "1 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. I shall employ persons subject to <br />WORKERS' COMP1= SATION Laws99'���� alifornia. <br />PLY I -T" <br />HE APMUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed <br />SEE/ SITE <br />- Title ' ��C J Date I/ <br />AP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY _ I <br />Application Accepted By �dKi�- "� Date Issued /Url S/ `jam Area L.O.Q <br />Grout Inspection By 4 ��A,11- C/Date !U �%� Final Inspection By <br />iii Date <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: / <br />Date <br />FAC# <br />I <br />ACCOUNTING ONLY AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CrH//E CASH <br />RECEIVED BY <br />DATE I PERMIT/�SSERVICEq UCEST NUMBER <br />INVOICE <br />O / <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C - L)EC;LAKAI1ON <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />