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R - <br /> %9-21-1999 12:SGPM FRCP. 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 ^ <br /> (209) 468-3449 <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 compA <br /> San Joaquin County Development Title, Chapter 9.1115.3 and the Standards of San Joaquin County Public with <br /> Public Health Services,Environmental Health Division. <br /> WELL Location-155 I I r CrossSires[ _I GAssessors y <br /> Q I City <br /> -`�}s2 iP Parcell `z7�/rt�A I U�`1(x!1 <br /> PROPERTY Owner�i I r1 �1 (1D Address y"(a1 Fnifti ' f ' yQ i FfQ fl 1 5 <br /> ry ZiP p �t hone# 1 <br /> C-57 Contractor r III Address •Q-C)()1/ ` ��ty It Zip _7) Lice 7p)UI�(phone# 707 37l <br /> =ConsuftantSub Contractor ATC A/-tJCCIQfC/7`J Address) LL Mem D6 WCiryQ () c# NIA, phon 9 �(O 5tt) <br /> GIS Coordinates;X ,,Y Township Tc) Ran a��� Ir' fSection— <br /> WORK <br /> 9 Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT.GEOPROBE. HYDROPUNCH.HAND-AUGER.OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORING# <br /> WELL 0 OVER-BORE <br /> x_�y1—� <br /> 'Other: Q PRESSURE GROUT <br /> COMMENTS: I Q 1 <br /> PE OF WELL IN TALLATION TYPE CON RUCTION SPEClFlCAT10NS - ` <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE t l MULTIPLE CASINGS?Q YES \ NO WELL CASING CIA: <br /> Q EXTRACTION j]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q S LJGVC OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL Ill-L TREMIE TYPE TO BE uAUGERS QHOSE <br /> u AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE- A L DEPTH IS 30') <br /> a SOIL BORING 13 HAND AUGER APPROX.BORING DEPTH___:;' / BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: Il OTHER CONDUCTOR CASING PROPOSED? nn YES,list specifications here): <br /> COMMENTS' : p h.u&0,-k0(21 �-1 -71- /�I to a/n <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 agents signature certifies the following: "I cerrffy that in the performance of the work <br /> for which this permit is issued,l shall nor employ persons subject to WOR#CERS'COMPENSATION Laws of Calilomia" Contractors hiring or sub- <br /> contracting signature cerifies the following: 7 cert/fy that in the paformance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Callfomia." <br /> THE APP ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x �. T tie�� Date 9-a8-99 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATEDL,>/sem <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued - <br /> Area O 7 ST� <br /> Grout Inspection Byao Date Final Inspection BY Date <br /> — <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC0 <br /> PEC FEE INFO AMOUNT REMtTTEO HEC CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3g - a 3-:2C) <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE.&WORKERS' COMPENSATION DECLARATIONUNIT IV-6/23/99/sign bkpg/MI <br />