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WE_L PERMIT APPLICATION. ORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />E. Weber, Third Floor, Stockton, CA., 95202 <br />E0 " _x_1VE (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is here4�ji{ad jt$S4999quin 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 C;MPQNJM� I LTH S% ri p �js'?.�j/ Parcel# /S% ' 2l05/ — /� <br />CrossStreetag d Ci Zi <br />RMIT / <br />PROPERTY OE er 1 k A7} -t Address f v 13[%7k 3 Z -G —City Zip��Cw tink G n ctZ ip 3 Phone# --4-1 9 416 2 <br />tor rC-57 Contracdress ON A Y� city - c,V ipWLic# Phone# j7A'7 Z?�_ <br />Consultant / Address�/)A e26,! <br />City ic# Phone# 4•A !�::012- <br />GIS Coordinates: X,_ 7�, Y 7 ` , Township / J1/ Range Section SS <br />WORK TO BE PERFORMED <br />fi'NE'N WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />"Other: <br />COMMENTS <br />TYPE OF WELL <br />'MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />SOIL BORING # 3 <br />WELL <br />INSTALLATION TYPE <br />a-fiOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />'SOIL BORING 0 HAND AUGER <br />0 OTHER:_0 OTHER <br />COMMENTS <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />GUNS I KU(- i IUN JF'tl.Irll.A I IUN,3 <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES AINC //WELL CASING DIA: 3 y <br />CASING THICKNES d TYPE OF CASING: 0 STEEL @-PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Sb I W16OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications h <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, 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' COMPENSATION Laws of Califomia. " <br />THE ApfLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title `''�^ Dates <br />SEE TE MAP IN UNIT IV WORK PLAATED 3 199 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued %/i 1/6 Area O <br />Grout Inspection Byc, Da,��c� Final Inspection By Date <br />Destruction Inspection By GtGN Date" - 4�'� Sui�`"c9Lwo(' <br />COMMENTS / CONDITIONS: <br />O <br />\lt <br />FAC# <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK /CASH <br />RECEIVED BY <br />DAT UE NUMBER <br />INVOICE <br />j Sp <br />- <br />C�) <br />7�r (rSR# 0 D // d 7(, <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS ENSATIO EELARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />