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WELWERMIT APPLICATION ORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IVSD <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 b 1999 <br />(209)468-3449 <br />ENVIr i , ,- HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PL . " - - .;':+MILES <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 />77 �S`T Assessor's <br />WELL Location "� Cross Street �'0 City Zip f 2 ``arrcel# <br />PROPERTY Owner <br />,�lI _ �p�-✓! / s&rYA-ddress pc% , ,' '� 5'-f City S- Z-�Z� Zip f one# <br />C-57 Contractorl�Gf-��tet�- C % Xdttfd'ss }' J lDl /%rLcaty. ;� �J 7 �'I�ione# �? m66 <br />Consultant / Sub Contractor Address City Lic# Phone#� <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />\ WELL/ BORING (CPT, EOPROBE YDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />\ 0 G # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />*Other: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA:_ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS OHOSE <br />p AIR SPARGE SH POINT GROUT SEAL PUMPED: O Yes O No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />OIL BORING O D AUGER APPROX. BORING DEPTH ZS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />O OTHER:_0 OTHER CONDUCTOR CASSI�IIN�^G�rP-ROPOSED? ( if YES, list specifications here): <br />COMMENTS.- O/) Q F Ih./�1gC <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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE <br />I/APPLICANT <br />t M{U�SSTT CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />9 9 <br />Signed x ��%t�r��1/°l�'. // Title 601 fD tni.� Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued o Area <br />Grout Inspection By In, Co V- Date 1Z Final Inspection By z Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />ase <br />$g`f. vol <br />(Rcil,co <br />30(, <br />jz IO q21 <br />SR# ooa <br />C-57 LICENSED_ CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />