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: . FILEuWELL PERMIT APPLICATION FORM WT <br /> GST � <br /> 2 2_0,01 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209y468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct ant!/ar install the work described. This application is made in compliance with <br /> San Joaquin County Development <br /> Title,Chapter 9-1115.3 and the Standards offSaanvJoaquin County Public Health Services,Environmental H iv on. -7 <br /> WELL Location ly6 /� L c� FZ Cross Street //rj����v* Assessor's � Py� ` _> <br /> t%!L i�' C' c,/✓S i �L C 77C/v Zip Parcel# f� ��1L2 <br /> PROPERTY <br /> C-57 Contractor /2-2e <br /> Consultant Address ,e C ���r7Y% �'J G -�7 <br /> Y 1 Cti► Phone#-S / G ,5-0 S' C 92 Z <br /> GIS Coordinates;X (L_�L' �fQ Y J/J'S b00 Township <br /> P � � Range %. � .0 Section F <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER OTHER') 0 DESTRUCTION <br /> 0 SOIL BORING# (choose type below) <br /> WELL# Q OVER-BORE <br /> -Other: A 0 PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0,HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES XNO WELL CASING DIA-2- <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C.- <br /> lyG TYPE OF CASING: 0 STEEL XpVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3�'% TREMIE TYPE TO BE USED: KUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. 18,Yes (]No `NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH_ ??3 <br /> 0 BOLTED TRAFFIC BOX or U�ItTOVE PIPE <br /> 0 OTHER fl OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <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,/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'Cq9P,,ENSA TION Laws of California-" <br /> WTHtAPPLrAPUST CALL 48 HRS IN ADVANCE FOR LL REQ RED SPECTIONS. <br /> Signedx LiLLZ4Ls <br /> Title ate <br /> SEE IE MAP IN UNIT IV ORK PLAN DATED �"7`29-C �D <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued /V�J � Area <br /> Grout Inspection B ;, 1&l U <br /> Date Final Inspection By Date <br /> Y <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: W r <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> G_S7.LI,CENSED..00N'I ACTORMIJST_SIGN LI�E�FSE &WQ�KERS'Cf7NIP 1 I TION-DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> `i WOb9 "VVC:8 6661-9Z-L <br />