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10-04-1999 10:32AM FROM P 1 y <br /> r <br /> WELL PERMIT APPLICATION FfQ:Ri111L1_�' 111,12, 7YNIT IV <br /> i <br /> Q , <br /> _ SAN JOAQUIN COUNTY PUBLICHEALTH-SEkVICESI <br /> ENVIRONMENTAL HEALTH E(VISION (PHS-EH©) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-RI=I=UNOASLE PERMIT EXPIRES 7 EAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app4catior,is made in compliance with <br /> San Joaquin County Development Title, ChaPlar 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> I+ LL I- f i� Assessor's <br /> WELLLocation 4ol &wtk LIYc lyi 'S Cross Street CkUYC�tS City A&C�T0V1 Zip Parcel# tY7_r-03J 03 <br /> s <br /> PROPERTY Owner KcVIVI Basso Address 1145 W. Gk4kel wet/city S+ock+ovt Zip gs2ote Phone# zoq-4r�lo -sl�l� <br /> Myr��wcx q¢553 <br /> 415.51 L4 �i25-313 �rbaa <br /> C-57 Contractor Cry,,I D r 114 I yl Address 5o I�n fie✓ R City Zip Lid# Phone# <br /> X 19 $ mrvy►/rlly C.a3°t7o7 5to tvSZ 37-7,7- <br /> Consultant/Sub Contractor I e s Address p 0 8° City Lic` Phona# <br /> GIS Coordinates:X Y _—.Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTH R") 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# _ I?OVER-BORE <br /> Af WELL# - -3 p PRESSURE GROUT <br /> 'Other- <br /> GOMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> 't <br /> ,(]'MONITORING ,B'HOLLOW STEM DIA. OF BOR> HOLE q7" MULTIPLE CASINGS?[]YES D NO WELL CASING D]A: <br /> D EXTRACTION [I AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL ) "PVC o OTHER; <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: !7 AUGERS DHOSE <br /> ©AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: n N,es Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING ©HAND AUGER APPROX. BORING DEPTH 25 r n BOLTED TRAFFIC BOX or ❑STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PRO OSED? (if YES,list specificatians here)! <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws,and Rules <br /> anal Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKER 'CO MPENSATION Lave&of California." Contractor's hiring or sub- <br /> contracting signature certifies the following; 'I cenity that In the performance of the wo for wh;ch this permit is issued,1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomio. <br /> THE APPLICANT MUST CALL 48 WORKING HRS INA .VANCE FOR ALL REQU,IREP INSPECTIONS. <br /> Signed x Title 6 KSV 4},1yI - Date 1i I?� <br /> Pe L°o" <br /> SEE SITE MAP 1 UNIT IV WORK PLAN DATED: _nI 1vo! 'I 'l <br /> DEPARTMENT USE:ONLY <br /> Application Accepted By Date Issued ]Area <br /> Grout Inspection By ����a�0�. _Date mal Inspection By�nAWy f ik1W3 11,k, Data <br /> 77 Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> EACCOUNTING ONLY; AID#ES FEE INFO AMOUNT REMITTED HECK RECD Y DATE PERMIT/SERVICE REQUEST# INVOICE i <br /> i <br /> 1115 l r <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE WORKERS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />