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WEllPERMIT APPLICATION 1-ORM <br /> <br />UNIT IV <br /> <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 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 ;2q)_o i)-). Turner R.oc,op <br />PROPERTY Owner Q\C)e rir Mc-(a Address I Ocict tit), (3 C.Arri+11-A City Zip9501V) Phone41,4t) -37?1 <br />C-57 ContractorIl/qtAnt t Dr I im7 A dress s.„..0. 5-36O kAAtiAte.citb60-60,c,tozipe) sT026Lic#6-7)417 Phone('6) 31 • Yaci <br />Consultant / Sub Contractor Address L/005-J(/ L)67 City --C46(-1-7‘ti Lic#(40) 7 Phone ) Y67 -2.066 <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED <br /> <br />. Assessor's <br /> <br />Cross Streettpv-er c4C2 61iitity Loa I Zip 95,)11)- Parcel# <br />;KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />fl SOIL BORING # <br />*Other: <br /> &WELL # /KVA An '2 I ivu A .1 !Ng <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING $1, HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />POTHER: I:I OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S" MULTIPLE CASINGS? 0 YES KRiO WELL CASING DIA: <br />CASING THICKNESSA.He 4/0 TYPE OF CASING: 0 STEEL :TOVC fl OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS 0HOSE <br />GROUT SEAL PUMPED: 0 Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1i.45 (if YES, list 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: "/ 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 California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title 54A-cf— -e.0(.!)7/5t. Date 9 a 00 <br />61-i64rt • "II/01W <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: Pau <br />Application Accepted 7 <br />Grout Inspection By t <br /> <br />DEPARTMENT USE ONLY <br />Date Issued 3/n/o0 <br />Date3f.-V,/c.0 Final Inspection By <br />Date <br /> <br />Date <br /> <br />Destruction Inspection By <br /> <br />Signed x <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />_ <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT rgERVIC - QUEST # <br />M -Voo rs7R-# Oc2v-I-I6s. ------) <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' PENSAIO1 DECLARATION <br />UNIT IV - 6/2 3 /9 9 /sign bkpg/MI