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`C- WELL- PERMIT APPLICATION PRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES cD <br />r-, <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 c, <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 irircompliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environme ll Health Division. <br />T 7 ��- Assessor's <br />WELL Location 7 Cross Street�% �/ �L City 4 L Zip 'F-5 Parcel# <br />PROPERTY Owner — Idr Address �Z) //nom �T City ���t 1 Zip Phone# 7 l �'� <br />C-57 Contractor 4464g1wi Address �� / V D� (, ?JCity t Zipg��ic UPhone# 7 t <br />Consultant/ Sub Contractor rT b'C Address City Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />SKEW WELL / BORING ( CPT GEOP^ ROB�YDROPUNCH <br />ILBORING # <br />0 WELL # <br />'Other: <br />HAND -AUGER, OTHER-) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 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: 0 AUGERS OHOSE <br />0 AIR SPARGE GUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') _ <br />OIL BORING 0 HAND AUGER APPROX. BORING DEPTH * / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />—1__ <br />COMM <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, l shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT -MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x�'Gdr,,t'i /UCS Title '/ ' �C Date_ <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: -i$--5 2 <br />DEPARTMENT USE ONLY <br />Application Accepted By ,�,p�(� Date Issued /y "-", - �! 9 Area 0 ?J -C <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date /O�a9/gq G; ,�,Q to /7 <br />COMMENTS / CONDITIONS: <br />Z <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER RVIrF RE <br />INVOICE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C-OMPXNATION DAF ARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />0 <br />