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9-22-1999 4:00PM FROM N. a <br /> VpED <br /> WELL PERMIT APPLICATION FORM MAt <br /> B <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES tu ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") [' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 O �-I �i 5 <br /> (209) 468-3450 W <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 compliancewith <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,EnvirAssmaental sots Health Division. <br /> WELL Location ay4�i E SVP 140v\t ST Cross Sheet FiIDu^t 6T City 57.0 a1 Lp ?5,t°S Parcel# <br /> PROPERTYOwner LI It of- Mde-t-AA Addre3s9a5,N. t-IpWde 6f _city Sr°44�tw1 Zip �✓`zo� Pnonetta09-937-B3py <br /> C-57 Contractor/wee iln S)-Ft1 Addmss 950 opwt � crty/NClP7),'a zip ?95P Uc#�7Phone#9.15-3/3 f$60 <br /> ,,�,�� <br /> Consultant)Sub ContractorC4nabrta CylV, Address r27 o ;Pa( m S?• city � 4 Uc#`�l� Pnonaa7o7-93S-vasa <br /> GIS Coordinates:X <br /> Y .Township Range Section <br /> WORK TO BE PERFORMED er <br /> NEW WELL 1 BORING CPT EOPROSE.HYDROPUNCH,HAND-AUGER.OTHERS Q DESTRUCTION(choose type below) <br /> SOIL BORING# S -� Q OVERBORE <br /> Q PRESSURE GROUT <br /> Q WELL# <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFlCATIONS <br /> Q MONITORING Q HOLLOW STEM DLA­ OF BOREHOLE d" MULTIPLE CASINGS?Q YES �q NO WELL CASING DIA;__ <br /> rJ EXTRACTION Q AIR HAMMERIDRIVEN CASIN R TYP OF CASING: Q STEEL Q PVC Q OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS pHOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL $Yes Q No (NOTE: MAXIMUM FREE-FALL DEP ) <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH--f.S' Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> N <br /> Q OTHER: CONDUCTOR CASING PROPOSED? of YES. list specifications here): <br /> %I-------- <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this application and[hat 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: of cerdfy 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 Califomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work Ior which this permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> EAP ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. / <br /> Signed z -"��`-- <br /> SEE SITE MAP I UNIT IV WORK PLAN DATED .- �/3 �=�� �� <br /> DEPARTMENT USE ONLY S--S�� <br /> Application Accepted BY <br /> Date Issued Area <br /> Date Final Inspection By Date <br /> Grout Inspection By - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK1hCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> sip17. 0 2160S <br />