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WELL- ,'ERMIT APPLICATION . RM 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 HP-ith ni„ice;,,,, <br /> ,{ L., Assessor's <br /> WELL Location2r`(� (ItIN� S;]TR 1� StreetS-(ALiTcf-0;A, CitySTTC_Kt0Ki Zip`/5 -d(- Parcel# 1�7-c'�o 25- <br /> -Cross <br /> PROPERTY Owner(' 'lO ?ALi0(, KthL?0”IroAddress I41b,Dotcx Sf• , IcoM�� City IAq t -Zip69k-1-11 <br /> C-57 Contractor 4 W MLLitiCi . V(_ Address lab Rr- SiREcT City�LC,TDIJ Zip'157.4I Lic#�7� Phone#9f6-77�-.#top <br /> Consultant/Sub Contractor`oNODR t7tt}fiELrFnbt�7h(bSFlddress Fb N?AtX WnT(tR S�V.T City S'M*-taN Lic# Phone#W•i-73 <br /> +097 � <br /> GIS Coordinates:X Y Township 1 Range wi% Section <br /> t <br /> WORK TO BE PERFORMED <br /> )'NEW WELL/BORING(CPT, G O� PROBE, HYDROPUNCH, HAND-AUGER, OTHER•) DESTRUCTION(choose type below) <br /> 'ASOIL BORING# 'Zi 0 OVER-BORE <br /> 0 WELL# p PRESSURE GROUT <br /> *Other:Ltocw <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING XHOLLOW STEM DIA. OF BORE HOLE-'3-i'l 6 MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA:__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 'N Pr TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED; gAUGERS NOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )L Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTHy Or 0l ttF6r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_ 1OTHERARkCT PA`S H CONDUCTOR CASING PROPOSED?. (if YES, list specifications here): __ <br /> COMMENTS: M1kT1C-1 J6LS 6.Prd-uwC . DTC-cr Pmt+ A-zJD *LcOW <br /> _$TtM /fi�Ly�Z <br /> 60tiLIN65 FDKSOtL Atib CJ?-cUN0WAT69-'1A&eLE-S - IJD VC 9, iA-NCE J WliL S i0 1k� -rrQSr 1L_LED. <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 of 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 subjgct to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE AP LICA MUST CALL HRS IN ADVANCE FOR ALL REQUIRED INSPECT ON <br /> ' o L <br /> Signed x � _Title C>VV• �R�,f� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED Ap�IL I � Z�3 <br /> }� - DEPARTMENT USE ONLY / <br /> Application Accepted By (/ �� Date Issued Lf Z g O 3 Area__ <br /> Grout Inspection By Date Final Inspection By r Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 0c,kc) ( `6 .o 0 oS4�I G& 14[2+31 0 0 3 6 l O <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br /> I <br />