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Ma 02 00 08:50a HYDRO-GEO CONSULTANTS, INC 650 -428-0589 p.1 <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) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and <br /> install the work described. This application is made in compliance with 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 2' 11- 14-i-e Assessor's Cross <br />PROPERTY <br />Street E. /V %/le A- <br />Ac <br />City A.- 7:-Zip_Parcel# /3 - 2 5-0 - o S- <br />C-57 Contractor 0//V (0E-Y <br />Ce‘ ta2r 1P/ 14-4-4-‘.1"1.-1 if3'""C't Phone# <br />Address217/€7 c4-.•4i7 Cityfrrni,ord- zip915/SYS-Lic.Phone g <br />: <br />Consultant / Sub Contractor -6°4, Conso/44/kddress /;!42- 4. 4135-3 <br />GIS Coordinates X <br /> City elike_Lict,-• /-16 37 ,5- phone rk <br />WORK TO BE PERFORMED <br />O NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />a SOIL BORING # <br />0 WELL # 'Other: /ft ea 7-- PI-1 5.4i PfeSi a es <br />COMMENTS: <br /> Township Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />PRESSURE GROUT ckr--7 44 1,7/ T r4 AT c EJA-1 CAI T3 <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING a HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />I] AIR SPARGE 13 PUSH POINT <br />SOIL BORING C HAND AUGER <br />D OTHER: OOTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />TYPE OF CASING: U STEEL 0 PVC OTHER. <br /> TREMIE TYPE TO BE USED: 13 AUGERS 13 HOSE GROUT SEAL PUMPED: El Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, fist specifications here): <br />COMMENTS: 7c) ge- Sez-m 47 C) /14-1141 EPIATC-1.-Y AFTC-12 S /444 PL/1.14.. <br />contracting signature certifies the following: I <br />certify that in the performance of the work for which this permit is issued, I shall employ persons subject to WORKERS' COMPENSA770N Laws of California." <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." <br />Contractor's hiring or sub- <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ <br />certify that in the performance of the work <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 />TH APPLICANT MUST CAL <br />NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PER <br /> Titlett <br />48 WORK!NP HRS IN ADVANCE FOR REQUIRED INSPECTIONS. <br />SEE 1TE MAP IN UNIT IV WORK PLAN DATED: <br />Signed x <br />Date 5-/Z/i2V <br />DEPARTMENT USE ONLY <br />Application Accepted By 1-- <br />Grout Inspection By 1/0•4,--4A,A.AP-AP-5^, <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />. Date Issued I 7-100 <br />Date C I 7-2-1 cc, Final Inspection By <br />Date <br />Area <br />Date <br />ACCOUNTING ONLY: AIDIt <br />FACA <br />PE CODES FEE INFO <br /> 5-12/11 <br />C-57 LICENSED CONTRACTOR MUST SIGN ucgNsE 8c\VORc,,E1S' C UNIT IV - 6 /2 3 /99 /sign bkpg/MI <br />5-0 <br />AMOUNT REMITTED <br />11)S°I.00 <br />CHECK # <br />. LUS <br />REC'D BY <br />1/4c <br />DATE INVOICE <br />z-G <br />TION