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11-01-1999 9: 13AM FROM0 <br /> t 0 P. 3 <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 andlor 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 /> 11 `� Assessor's <br /> WELL Location yl/Gz S w/rl2�� � 1 rctY Cross Street 1-41"4C/ity' 7 Zip Parcel# <br /> PROPERTY Owner �/�US C l S Address ?�!1 2 S` �J► ��+�rbsJ City_ Zip 9537b Phone# zo9 633-7G,xI <br /> C-57 Contractor Address 3 City _Zip9 Lic# ` `Phone# tj <br /> L►J ?7Yt1 it i15,1 nc. Po-Sax 5/ 72.e t> I/s, 4 9 571 7Zo90 f <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X , Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> J_'501L BORING# B S Q OVER-BORE <br /> p WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING DIA. OF BOREHOLES LTIPLE CASINGS?Q YES o NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0 PVC Q OTHER: <br /> o VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS OHOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;POIL BORING [j HAND AUGER APPROX.BORING DEPTH 2,,!P Q BOLTED TRAFFIC BOX or p STOVE PIPE <br /> Q OTHER: R"'OTHER r CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: �it'�°'6o4IAM so/G efn�IQA 90WN4 1007 -Bc�uJl9i�//��✓1� <br /> 2 ' AAViO- 4 w S-v e,,,777^1 -S <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,1 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 /> THE APPL1 NT FUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY / <br /> Application Accepted B I Date Issued u Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: 0 <br /> ACCOUNTING ONLY: AID# FArA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT i SERVICE REQUEST# INVOICE <br /> DO <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WO RS'CONII'ENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />