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9-22-1999 A:00PM FROM P•� <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <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, Environ entoal Health Division. <br />WELL Location Gi Acol(it 5T• Cross Street W ' c vlq{'y'6y'w City �Tack_t^t zip 954D-6 Parcel# /65- D3 <br />puT�' ` <br />CC rr 1 t , � ��' � �c'X� � 1` � . City C'� <br />PROPERTY Owner C t 1�-���t�Q �- �• �'S 6L` _Address <br />,Q j���tr>.ez z�pyY 5 Lrc#�5 Phone# 9a✓� `�13' SBad <br />C-57 Contractor ,��bT I I I I ✓1A Address io lw R'^ City="°'-- <br />` a� PVkivt5 ST. Cityr� 040 <br />r,-. —irn�t i Suh Contractor CAM I A Y U Address <br />GIS Coordinates: X Y , Township <br />WORK TO BE PERFORMED <br />a NEW WELL/ BORING ( CPT, GEOPROSE. HYDROPUNCH. HAND -AUGER, OTHER") <br />BORING # <br />Range Section <br />)(DESTRUCTION (choose type below) <br />rA W _ OVER -BORE \\ <br />PRESSURE GROUT <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! ' <br />that I have prepared this application and that the worts will be done in accordance with San Joaquin <br />Co that yordinances. State Laws, and Rules <br />performance of the work <br />1 nd Re certify t <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following. " Y <br />for which this permit is issued, !shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature t is certifies the I shall <br />'l certify that s the performance of the work for which this permit is issued, i shall smploy persons subject to <br />WORKMAN'S COMPENSATION Laws of Cafifomia. - <br />HE APP NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />_Ga� <br />TitleSigned x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED — <br />DEPARTMENT USE ONLY <br />r <br />Date Issued I �' � � �' � Area <br />Application Accepted By <br />By <br />Date Final Inspec <br />Grout Inspectiontion By <br />Destruction Inspection By Date <br />—IMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />3`� L <br />AIDS <br />AMOUNT REMITTED <br />`0 6,t , cc <br />CHECK#/CASH <br />-rt 4 - <br />RECEIVED BY I DATE I PERMITISERVICE REQUEST NU <br />0 <br />0 WELL # <br />Q <br />'Other: <br />C,-MMENTS: <br />WELL <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />YES Q NO WELL CASING DIA; <br />DIA_ OF BOREHOLE_ MULTIPLE <br />CASINGS? p _ <br />JNITORING <br />HOLLOW STEM <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS SCh ND TYPE OF CASING: a STEEL PVC Q OTHER: <br />EXTRACTION <br />f� VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL <br />No <br />TREMIE TYPE TO BE USED: Q AUGERS pHOSE <br />(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />AIR SPARGE <br />Q PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes a <br />DEPTH '" S <br />D BOLTED TRAFFIC BOX or STOVE PIPE <br />n SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING <br />CONDUCTOR CASING PROPOSED? <br />( if YES, list specifications here): <br />OTHER: <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! ' <br />that I have prepared this application and that the worts will be done in accordance with San Joaquin <br />Co that yordinances. State Laws, and Rules <br />performance of the work <br />1 nd Re certify t <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following. " Y <br />for which this permit is issued, !shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature t is certifies the I shall <br />'l certify that s the performance of the work for which this permit is issued, i shall smploy persons subject to <br />WORKMAN'S COMPENSATION Laws of Cafifomia. - <br />HE APP NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />_Ga� <br />TitleSigned x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED — <br />DEPARTMENT USE ONLY <br />r <br />Date Issued I �' � � �' � Area <br />Application Accepted By <br />By <br />Date Final Inspec <br />Grout Inspectiontion By <br />Destruction Inspection By Date <br />—IMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />3`� L <br />AIDS <br />AMOUNT REMITTED <br />`0 6,t , cc <br />CHECK#/CASH <br />-rt 4 - <br />RECEIVED BY I DATE I PERMITISERVICE REQUEST NU <br />