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WELL PERMIT APPLICATION FOKA ,UNIT IV <br /> n _ <br /> F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `= <br /> i� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <br /> tJ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <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 comPfilince with San <br /> Joaquin County Development Title, Chapter 9-1115..3 sand the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location i31 V ) /'e.1 61 ,UJ'f L�I� .:1C.• Cross Street City �,�)(�t✓"ISL—Zip Parcel# <br /> Assessor's / 2 � <br /> PROPERTY Owne rl1-SGlrh1C ��-rh�K� . Address,3f j 5• FI yc I 5 • C,ltyi., ' k�-lty/n ZiI .�t^ J�,, 'Phone#� 9 -��O�a-tP�fy <br /> C-57 Contractor .lf C AddresST.0 ISO CityJj5[&n—ZipCA7 Lic# 09V Phone# 'yJW <br /> � p� J I 6p g51o41 <br /> Consultant / Sub Contractor Yrf J_. T <br /> nOCI C. Address Po- L7uX CMCItylka Uc#A-h19/�4+hone09, -F�r'2 /3 <br /> GIS Coordinates: X., y., Township lei PJRange 0w E Section I Li c2'T <br /> W///OIIIRK TO BE PERFORMED: <br /> WHEW WELL / BORING ( CPT, GEOPROBE, HYDROPU CH , HAND-AUGER, OTHER*) n DESTRUCTION (choose type below) <br /> IP' OIL BORING # [] OVER-BORE <br /> ELL # I] PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL `INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �ItTOLLOW STEM DIA. OF BOREHOLE 11 MULTIPLE CASINGS? [I YES 0 NO WELL CASING DIA: <br /> ] EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL �'iPVC�"Q OTHER: <br /> [1 VAPOR ]] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: A{yvUGERS []HOSE <br /> 1)^AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: '�J/� eess �[I No ( NOTE : MAXIMUM FREE- ALL DEPTH IS 30') <br /> VIISOIL BORING H HAND AUGER APPROX. BORING DEPTH ' X J 1 [] BOLTED TRAFFIC BOX or H STOVE PIPE <br /> TTTTTTa OTHER U OTHER CONDUCTOR CASING PROPOSED? ( 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: '7 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: 11 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS' COMPENSATION Laws of California. " <br /> * CALL THE NIT I SPECTOR 48 WORKING HRS INADVANCEFOR ALL REQUIRE' D INSPECTIONS <br /> Signed x / Title/Company JI ff6(k rte° <br /> Print Name I _Date__! <br /> SITE FILE ADDRESS/WORK PLAN DATE : <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area 0 7SG <br /> Grout Inspection By Date //- 7 � C/O Final Inspection By Date <br /> . <br /> Destruction Inspection By �� r� Date <br /> �i- <br /> COMMENTS / CONDITIONS: (ISL — S1Oc �� ro._ d6 <br /> . 4 _ f'�— Oj 1' 8.31 <br /> Iota <br /> ACCOUNTING ONLY: AID# EACIt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 35i� 1 89 - 89 - <br /> 015v3 CIO 11 'V7410 SR# 0031y7349 <br /> C- 57 exp ._ WC/waiver C-57 Letter of Authorization to sign permit_ Encroachment doc(s). 5/ 17/00 <br />