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1-28-2000 2:41PM FROM <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />P. 3 <br />UNIT IV <br />'yF �vy <br />JAN 0 8 2001 <br />(209) 468-3449 ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SER\/ICES <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 />C f Assessor's <br />WELL Location n fi I e 'f C h H o 1lf Cross Street S4cc k+o r, s City. \t r o d` Zip � 5 7 Parcel# <br />� �r7 � h G 7 <br />PROPERTY Owner A; P.. � e k S i e tl Aj { f g �eo io Address S4oc V:4 Q o City C A j Zips) 5 7613 Phone# 2— OCf - 9/ , -7DS'9 Cp <br />C-57 Contractor 1r, T a, CC,Addressr66a33( City Zip/ ic#71�Phone#_] 7—,��y <br />� <br />,� �nJ � G 1 /L �. <br />Consultant/ Sub Contractor l4AQL66)b FSE Address iVZ65IC ,*/! t haft City � 1 Lic# Phone# Y 3 �9. -0 Zg3t <br />GIS Coordinates: X , Y , Township td Range �' C, Section 10 <br />WORK TO BE PERFORMED <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />fn� 0 WELL # <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />D MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:—G <br />OTHER <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />0 OVER -BORE <br />'J'PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS it <br />DIA. OF BOREHOLE G" MULTIPLE CASINGS? 0 YES ;& NO WELL CASING DIA:Z <br />CASING THICKNESS D2j-" TYPE OF CASING: 0 STEEL /" PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USE�D: D AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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: "1 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 />/CALL THE UNIT IV; INSPECTOR <br />/48 WORKING HRS 'IN ADVANCE FOR ALL REQUIRED INSPECTION& <br />Signed x (r--^'�`L� 11 /` V Title/Company /r,}COGf9 TE l� POIO �t a5 7 //� CT /c�i ✓k i C�.S C <br />Print Name �^ A ✓•' 1-i Date Qi �) z / ,., .....,,....,.._ <br />.q�DEPARTMENT USE ONLY <br />� G 1( <br />Application Accepted By ✓ " -LL , Date Issued ( (. I Area <br />Grout Inspection By ((� n�C <br />Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />FFAr <br />COUNTING ONLY: AID# <br />1 <br />�J <br />11. <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE �PERMIT/ SERVICE ST # <br />INVOICE <br />:� L131 <br />