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11-01-1999 9: 13AM FROM• • <br /> P. 3 <br /> ,4 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES moi. <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) O� <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 /> Assessor's <br /> WELL Location 10C,01TIVA VAWc Cross Street i4 <br /> 11ftl City 22 4GX Zip Parcel# <br /> PROPERTY Owner zo- l Address 2-01775- /Y)40IZl ue City Zip ?5'-?-7(. Phone# &-9j' 635- �9/fit <br /> C-57 Contractor Address �� n' -city &ip 9-46 Phone#l!, <br /> V10 �✓ 7�n� �nJ, na R. 0. 3,X Si 72-io V167X 95,,'3'7/ 72--09"/AC7'7)374faa15 <br /> Consultant/Sub Contractor Address City LickPhone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> U NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# { a OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING DIA.OF BOREHOLE_MULTIPLE CASINGS?a YES "C WELL CASING DIA: kA <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Y`r'P TYPE OF CASING: a STEEL a PVC BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS OHOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER APPROX.BORING DEPTH 2-01 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> Q OTHER: YiPOTHER c+ CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: 4LCf Lt9/G M� z 561L -,F Q wlY7� /�6 d^��T G6�1� TU Z'• <br /> ,9 L1 50/e.5 7z? G/lby^'C> 1r✓/Zr'/k� <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: "l 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 AI PLJ�qCT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title �!' ���� � '{y�1 f c�L Date `7 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Z Area <br /> Grout Inspection By Date 1111&1'35 Final Inspection By DateI - U <br /> L <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ^ <br /> ACCOUNTING ONLY: AID# <br /> PE <br /> EECCODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WO RS'COMPENSATION DECLARATION <br /> UNIT IV-6/23199/sign bkpg/MI <br />