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11-01-1999 9: 13AM FROM <br /> 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 and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and theStandards of San Joaquin County Public Health Services,Environmental Health Division, <br /> L��10,5;0 Assessor's <br /> WELL Location Co/Z,eOGuo�� A"D Cross Street NkI�� City 7-)Z4'�'y Zip Parcel# <br /> PROPERTY Owner /t�i9alfTIF>� ?tr lr�4' �1`d Address I ZoG7 0, 4 + AO City Zip 9537 Phone# e�3S Sfr <br /> C-57 Contractor Address City fi*t- Zip 7b Lic#� Phone# <br /> V ri Ilr,s,JAG. n 0. 3jX -5 / IY o V,5M ?5 57/ 7 Z 7)3711,4-L8/r <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X , Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT. GEOPROBE, HYDROPUNC HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ,7SOIL BORING# 6 6� 7 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 10W DIA.OF BOREHOLEIVAIULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,VOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 7-c • 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: F,,OTHER_aWJ CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: Sm/L S TT&­Yb +i 76 e40'11'S :o <br /> 2 r 14'60✓6r G, rr7.�4 <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,l shalt 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, t shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLIC NT ST 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 A3y &�—Application Accepted By Date Issued AGrout Inspection By Date Final Inspection —Date-Ll- l <br /> Destruction Inspection By Date <br /> -- <br /> COMMENTS]CONDITIONS: �^ l <br /> ACCOUNTING ONLY: AID# FACtl <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ,L62�d DO S/� Lit 2 0 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WO RS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />