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fe/4 <br /> WELL PERMIT APPLICATION FORM IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD (',BAR 1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 5 2001 <br /> (209) 468-3449 EP:Vil')ON lr.-iv r H'AlFi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PE?PiI!1�� d i I k1LC <br /> /il,L� <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ^�-- Assessor's <br /> WELL Location �p �•L)% A\1F.T-FC 51 Cross S7treetCALIL L>,1111a City_S Zip��2-Parcel# q <br /> PROPERTY Owner H, !%;Li VA rr r: Address <br /> ^�J Co , /(°��`i A /City - <br /> Zipq5 `PPhone# G I <br /> C-57 Contractor AA AAAddress 296,7 w rGLI- M City ZipLic# E�Ciahone# <br /> Consultant/Sub Contractor r UI LL. F A)1-I,UV A1W ss�2��Zi PID 612K,4ty Lor) ( Lic# Phone# <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Y"NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# r".AMI 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING VOILLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?q<ES ONO W,LL CASING DIA:- rf <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40 Z TREMIE TYPE TO BE USED: 0 AUGERS 0<'SE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: es 0 No (NOTE•. ! MIM UM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH I ZS' i OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? Q_(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: "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 /> * QJ%LL T IV SPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signedx_& Title/Company C I()l L_F—(0Ijl2 f ji(T % L.L-- E-0061 L2L:, d ( <br /> Print Name �^n i' 12I ()1 '7�_ Date 3 Zig e2j <br /> SITE FILE ADDRESS/WORK PLAN DATE: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 'Z _0 1- MArea �� <br /> Grout Inspection By Date Final Inspection By Date 3•� �Z� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3g-c 3ZZ5 5 <br /> C-57 exp._WC/waiver C-57 Letter of Authorization to sign permit V Encroachment doc(s). 5/17/00 <br />