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10-04-1999 10 324M FROM P 1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 364 E Weber, Third Floor, Stockton, CA , 95202 <br /> (249) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the worst described This application is made in compliance wit"i <br /> San Joaqu:n County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Servacas Environmental Health Division <br />' WELL 4ol Soan�� I��Ih S� c�Nrc�I S� L�v Assessor's <br /> WALL Location � Cross Street City 5�ocff Y1 Zip Parte# <br /> PROPER'TYOwnor Keyra�a i�I5�a Address 114-5 0 cIn�rlr,� Fl,/.City `,l N52blp Zoci-4v(0 51`1 <br /> City Zip Phone-9 <br /> 9 5 0 +l i w e i2 Mn1 r I i n �]d 53 i a51 to T U, <br />' C 57 Contractor�g Yom. �r 1I Address City Zip Lic# Phone# �Z�_�13 <br /> p2,b 2'L 7& Emcvy,r11)r, (,o3-1 7o"7 10-tear? 3 v <br /> Consultant 1 Sub Contractor I L C-S Address Cary Lire Pnone#, _ <br />' GIS Coordinates X Y Township Range Section — <br /> WORK TO BE PERFORMED <br /> AY'NEW WELL./BORING (CPT,GEOPROBE HYDROPUNCH RAND-AUGER OTHER') 0 DESTRUCTION (choose type below <br /> ,$'SOIL SORING# J B—] OVER-BORE <br /> 0 WELL# a PRESSURE-GROUT <br /> 'Other <br /> COMMENTS <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MlJt_fIPLE CASINGS?0 YES p NO WELL CASING DIA <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC Q OTHER <br /> APOR 0 N1UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 113 AUGERS OH0S= <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 SOIL BORING 1) HAND AUGER APPROX BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIoE <br /> ' 0 OTHER p OTHER CONDUCTOR CASING PROPOSED (of YES Inst specifications here) <br /> COMMENTS <br /> iNOTE 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 Ordinences State Laws a^d R e <br /> anti Regulat ons of the San Joaqwn County Homeowner or S�censed agent s signature certifies the follow ng "!certify that in the performance oaf the worn <br /> for which this permit is issued. I shall not employ persons subjoct to VYORX ERS'C0MPJ5NSATION Laws of CaBforn,a" Contractors hiring or sub <br /> contracting signature certifies the following 'I certify that In the performance of fine work for which this permit is issuad 1 shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cahfomre <br /> ' THE APPLICANT MUST CALL 48 WORKING HRS 1N ADVANCE FOR ALL REQUIRE[ INSPECTIONS <br /> P /Signed x T�tl© CO r1s V�� "rt � Date 1111 2) '19 <br /> SEE SITE NEAP IN UNIT IV WORK PLAN DATED II q,III <br /> tDEPARTMENT USE ONLY <br /> Application Accepted By Date Issued _ _ _Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS 1 CONDITIONS �I <br /> ' CCOUNTING ONLY AID# EACA <br /> E CODES FEE INFO AMOUNT REMITTED CHECK* RFC D 13Y DATE PERMIT!SERVICE REQUEST# INVOICE <br /> r�t <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COxY VENSATION DECLARA-00NT <br /> ' UNIT TV-6/23/99 /sign bkpg/MT I <br />