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11-01-1999 9: 13AM FRO <br /> t P. 3 <br /> WELL PERMIT APPLICATION FORM <br /> 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 /> ,/����qq,,,, / n�j � Assessor's <br /> WELL Location /JI � �2 T�1j%GF.>1� l Cross Street �i1< City f,yi/� Zip Parcel# <br /> p � <br /> PROPERTY Owner �1 gecy� j Address � 0. & C 60 City 22?2!1C / Zip 95375 Phone# ( q2 835 3z10 <br /> C-57 Contractor CJS Address City Zip Lic# y;-Phone#�� <br /> Dry//,•HS', I N C- P 0- &OX sy TL.o ✓t s 774 , � 45"1 c 37q"L615 <br /> Consultant I 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- UGER,OTHER') jJ DESTRUCTION(choose type below) <br /> FOIL BORING# 8 21 $3 �QV p OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING /will N7 STEiat- DIA. OF BOREHOLE "' MULTIPLE CASINGS?Q YES a NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ®AUGERS QHOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )1SOIL BORING p HAND AUGER � APPROX.BORING DEPTH Zo r BOLTED TRAFFIC BOX or o STOVE PIPE <br /> Q OTHER: 0 � <br /> YOTHER ,01jW S fe t, CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: ALo�' Sa/G �aRIS $o>x.�CS �✓Lrti J�'c���e��A wiTt9 SeTO< Cth/� Z '.OBC✓t� <br /> �✓ S'v�2fist� . tic/l/cv S w/�� i3�a.$, -� 7a <br /> NOTE: OFFSITt 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 /> THEA 1C T MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x - Title <br /> /�A�l�l�/✓�/�✓Wf.c/L Date �' ��� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date IssuedAreal A1-0 C <br /> Grout Inspection By Date u Final Inspection y Date I/ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACIA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> lam- l <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WO RS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />