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WELL PWMIT APPLICATION ATION FOS... UNIT IV <br />J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />. 304 E. Weber, Third Floor, Stockton CA. 95 <br />(209)' 468-3449 ' 202 <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 />WELL Location yo f Eu -,7 /Y1.�,y Sl Cross Street D" City -t CA Zi C/'��� Assessor's <br />M S o� P Parcel#, ,C% • .26 v! G <br />PROPERTY.Owner Address Z <br />v 3 G City- � U Zips �7,I/ Phone 2 Fie 7 <br />/ f <br />C-57 Contractor �-K �V •Address FF s y /�'�^� G � <br />city S� �� Zlp��Lic# �P�p one# �!� • 777-1 <br />Consultant / xviw���D 1 Q Address_ U'' �$t�/7 Ci <br />w w..wia� 4. O�j ty <br />GIS Coordinates: X_, Y�'pTownship Range <br />_ <br />Section <br />WORK TO BE PERFORMED <br />`NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER*) c1 I Uk� Slt <br />(� - 7? 7 -J-0�. <br />0 SOIL BORING # 0 DESTRUCTIOiN (choose type below) <br />,WELL # 3 0 OVER -BORE <br />'Other: 0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />%MONITORING gHOLLOW STEM DIA. OF BOREHOLE A MULTIPLE CASINGS? Y ti <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sfd � d TYPE OF CASING: ES (VO WELL CASING DIA: <br />0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL D STEEL ,$,PVC 0 OTHER: <br />AIR SPARGE 0 PUSH POINT 7REMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH%S 1R;BOL7ED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? <br />( if YES. iist 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: "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 />TH A LIrQNT I!�UST Cr^•LL 4� I;�g ;,y AuV`r"�%10E hUF2 ALL REQUIRED INSPECTIONS. <br />Signed x/�/ <br />Title ate <br />SEE ITE MAP IN UNIT IN/ WORK LAN DAT -ED <br />DEPARTMENT US Y <br />Application Accepted By Date Issued 7 <br />Grout Inspection By J _Area 1S� <br />G. Date f Final Inspection By <br />Destruction Inspection B Date <br />� Date <br />COMMENTS /ONDITIONS: / SWtd2 �i/Cca� /yl�,1s ✓(y'r , <br />bACCOUNTING ONLY: AID# FAC# <br />iES FEE INFO AMOUNT REMITTED HECK/CASH RECEIVED BY DATE <br />f 8`t-0 C� /h <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />NUMBER I INVOICE <br />00,4 3 -5-/y :i <br />ENSATIO ECLARATION <br />