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WELL PERMIT APPLICATION f--,,)RM UNIT IV <br /> "ll" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RECEIVE C <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 16 1999 <br /> FG�OvG� (209) 468-3449 <br /> d---------- <br /> ���� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herb e to Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin Count Fment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> `ll y 1'L, c Assessor's <br /> WELL Location i"6f-i4- O.AQ— Cross Street ty" ✓) City S-FbCk Ivy) Zip Ts�p 7 Parcel# <br /> 3 r S k �z y' l 'Mil) <br /> PROPERTY Owner i � � Address � �• G� '�b City �C Zip of S Phone# <br /> C-57 Contractor f'ISc\r. �ylk h.e-•'-.JAddre��slI''s""""3So1 cYLS ��(�`-tk City\JA- '"Zp SZ�Lic#(o5"$�SPhone#7��-3 S�0 <br /> Consultant/Sub Contractor C—tr-LA-' (�� ddress (?Iy M4t✓' Sf, City �'S[IJOv) Lic# Phone# <br /> Co L <br /> GIS Coordinates:X , Y ,Township o; Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE o� �I MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: )(Yes0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> // <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Lt S 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> 0 OTHER:_0 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: "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. 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE AA(PP�LI�CpA�N�T, MUST CALL 48 WORKING HRS IN ADVANCE FOCR ALL REQUIRED INSPECTIONS. <br /> Signed x Q 0 �1 • _ Title t��a 6 7 l � Date !al f 11106 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> / t / � j�J� t► 0® Area L <br /> Application Accepted By t��.�✓�� Date Issued `I <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: D ��` �OS &// S, -O f l`ft7 <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Of 2A P-k lq nv SR# 062-31gis <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />