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WELL PERMIT APPLICATION rJRM 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 compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> c+� /� � _ /� Assessor's <br /> WELL Location I ss - lOc A" Cross Street 3<a S� = City�se�(CJrinn! Zip 5320 Parcel', <br /> PROPERTY Owner lC�Gt-e_�Qd 17 Address �jQIC �� City�.S[AXfJv,,_ Zip Phonem <br /> C-57 Contractor�r�L Address %5 Lf�irsa.9�m 9l Cit} Zip 55ZoSLic', 226 Phone',��,5'87/Z <br /> Consultant Sub Contractor(.M11_W1 4co Address 111J VAMa St City 5C%_ ►. Lic', — Phonem R38_06f <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> R1q_EBOR <br /> W WELL IN PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(chcose type be!cw) <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 IOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-'5'0-1;5 TREMIE TYPE TO BE USED: g-;<UGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER APPROX.BORING DEPTH _SD'GS� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: p OTHER CONDUCTOR CASING PROPOSED? (if YES,list specMcations here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> TH=PT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQU_ IRED INSPECTIONS. <br /> Signed x Title s� (2�c/Sr Date Zw <br /> SEE SITE MAP N UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY XXOTO <br /> Application Accepted By. Date Issued OC/ Area <br /> Grout Inspection By �,4 A 442,,q Date 11zn D Final Inspection By Date (I L` <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST.". INVOICE <br /> ;5 o 97,00 oIOaj <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMTENSATION DECLARATION <br /> UNIT IV-6/23/99/siqn bkpq/MI <br />