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WELLQERMIT APPLICATION FOM UNIT 1V <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 />{ <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DAT5JSSUED <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 IHeanh Services,Environmental Health Division. <br /> WELL Location 31»3c P47.c— Cross S �i Assessor's <br /> 1-J city <br /> i <br /> Parcel# <br /> !! it <br /> PROPERTY Owner L�.S• t- S-4-nJ rvfi r�Addressgo �n1d..LWrs%�I 1W City . Phone#g1L-373»$]D Z <br /> C-57 Contractor �"'1 •u+�.�. Address41 �►�+1�!'. Cit r ld ZiFC �[.�� 1 ? <br /> � .# Ir i <br /> Consultant/Sub Contractor b��eT Address iLge�Yr'-ir, 1� City'j A- Lic# Phone#G2L• G•I`ffi0 <br /> GIS Coordinates:X - Y Township I Range Section <br /> WORK TO BE PERFORMED <br /> _ t NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(choose type below) ! <br /> I SOIL BORING# W i-e— it l OVER-SORE f <br /> p WELL 4! j p PRESSURE GROUT <br /> *OtherI i��E. 8~ t.�C��oe.,] rr�-- Zr- Zl 4Wicftl „Y tri l 6t?r S 6.�.,,.-Jill `k <br /> COMMENTS: f <br /> I� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> Q MONITORING I HOLLOW STEM 01A.OF BOREHOLE S*� MULTIPLE CASINGS? ©YES I NO WELL CASING DIAD <br /> a EXTRACTION A AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING; (] STEEL OPVC OTHER: i <br /> p VAPOR a MUD ROTARY OEPTH OF GROUT SEAL "fir � !j'TREMIE TYPE TO BE USED: II AUGERS CHOSE I <br /> AIR SPARGE [I PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE? MAXIMUM FREE-FALL DEPTH IS 30') ` <br /> I SOIL BORING 1 HAND AUGER APPROX.BORING DEPTH Z-7 -Fr i} p BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> p OTHER: a OTHER CONDUCTOR CASING PROPOSED? o {if{,YES, list specifications here); <br /> Ij <br /> COMMENTS: I <br /> NOTE: OFFSITE BORINGS'REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> !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 thelfollowing: "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 cerfily that irl the performance Of the work for which this permit is issued, I chaff employ parsons subject to <br /> I WORK-ERS'COMPENSATION Laws of California. <br /> CAiE:�THE UNIT'IV' CTO <br /> R'48 WORKING HRS INADVANCE <br /> FO �ALLREQUIRED INSPECTIONS:` - <br /> L <br /> Signed TitleiCompany L- .-., I <br /> Print Name ;:-to-,gm Date 4/Il41016 <br /> - <br /> r,STFC>'MAP,.'IN A' <br /> SEE ,t. - <br /> DEPARTMENT USE ONLY li <br /> iI <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By ., Date <br /> Destruction Inspection By Date �1 l <br /> COMMENTS l CONDITIONS: Il t <br /> ACCOUNTING ONLY: AID# <br />, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE I PERMIT I SERVICE REQUEST it INVOICE j <br /> 1/18/2000 <br />