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WELL PERMIT APPLICATION ORM UNIT (V <br /> SAI`4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 711 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Stockton, CA., 95202 �? p <br /> ' 304 E. Weber, Third Floor, H 1: 39 <br /> W P (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ORIGi.NAL <br /> Application is hereby made to San Joaquin County for a permit to constr=and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 99--1/115/.3 and the Standards of San <br /> /Joaquin County Public Health Services,Environmental Health Division. <br /> �k Ou, Cross Street Gt{iaL City c'�' e Zip�Parcew# <br /> WEL.'-Location 7 / _ <br /> >b 1G �,3tY City Fv2e,",l � 523 Phone a '96 <br /> PROPERTY Owner ft?, �tuiritL —e-^k+'-5� -� <br /> ll �� 5 Cm k=Zip #5 GS W'*`-/Phone#q9-777-VICO <br /> C-7 Contractor Address / <br /> �/""�_ fr L b'a>c �Z Cyr K;R7VLid 9�5� Phone#2,W--)77�'6V <br /> Consultant/Sub Contractor �T►�;.rtf�l, t Address <br /> GIS Coordinates:X <br /> 9 v J Township _ Range Section <br /> WORK TO BE PERFORMED <br /> Ew WELL.BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) Q DESTRUCTION(choose type below) <br /> r` Q OIL Q OVER-30RE <br /> SBORING SOIL x 3 Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONS T RUCTION TYPE CONSTRUCTION SPcCIF1C.1T10NS -40 <br /> �► <br /> MONITORING HOLLOWS M 0Lk OF BOREHOLE �fc MULTIPLE CASINGS?Q YES 1 . <br /> 1 c „ WELL CASING OLA:2- <br /> ( Q OTHER:- <br /> EXTRACTION Q AIR HAMMERJORIVEN CASING i HICKNESS �� G T`(PS OF CASING: Q STEEL C Q <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL /jL_ 'REMIE TYPE TO 3E USED: JAUGERS QHCSc <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER APPFtOX. BORING DEPTH ?j P0LTED T,RAFFIC BOX or Q STOVE PIP= <br /> a OTHER: CONDUCTOR CASING PROPOSED,7 NO (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i nereby certify that I have prepared this application and that the wont will be pone in a=rctance 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: It certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractoes hiring or sub- <br /> of <br /> signature certifies the following:'I certify that in the penbmtenoe of the work for whictr:his permit is issued.1 shall employ persons subject to <br /> wORKMAN'S COMPJVSATION Laws of California.' <br /> HE APPU ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> ((7 LG'l�c�-- title ''�' :t.,Gecz"C Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY . / <br /> Application Accepted By Date Issued 0 Area O� <br /> Grout Inspection By Date Final Inspection By Date ` <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: W d <br /> FAC: <br /> FACCOUNTING ONLY: I AID* <br /> CODES FEEINFO AMOUNT REMI1.EDI CHECKSICASH RECEIVED BY DA iPERMITISERVICE REQUEST NUMBER INVOICc <br /> I ! I Ib-a- 23/oz I <br /> UNrT IV-5/99/MI <br />