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WEL?PERMIT APPLICATION MRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI EC E I VE D <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 14 2000 <br /> (209) 468-3449 ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Health Division. <br /> WELL Location—X60 j.Qp1h 6 DI &AQ#1Cross Street City G h ZipAssessor's <br /> —Parcekl <br /> PROPERTY Owner L40ss <br /> O.1L _,_Add,,ress �O�I'Q� City _Zip%213 P4416-5701.�101 <br /> C-57 Contractor AGE _ Address f w 1 h City%(�—zip�LicNi!Pphori6 <br /> Consultant/Sub Contractor, Address LOON #,. 6m W City,4A h UC* Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> V,NEW WELL/BORING(CPT,9EOPROBE,HYDAOPUNCH,HAND AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 0 WELL# <br /> *Other: a PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUC N SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 00 WELL CASING DIA:" <br /> 0 EXTR6CTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:, <br /> 0 VAP( t 0 MUD ROTARY - DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ,�IAOSE <br /> 0 AIR SPARGE JOUSH POINT GROUT SEAL PUMPED: 0 Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,$$OIL BORING 0 HAND AUGER APPROX. BORING 0 OTHER CONDUCTOR CASING PROPDEPTH ,_„ QQ_0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: OSED?�(if YES,list'speions here): <br /> COMMENTS: .. r <br /> AfL S �� Y►'L��s <br /> NOTE: OFFSITE BOR-1111 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 a'gent's signature certifies the following: 111 certify than the performance of the work <br /> for which this permit is Issued,/Shall not employ persons subject to WORKERS'COMPENSA77ON Laws of Calithmia." Contractor's hiring or sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T IrE ADPL CAN T£A4L 48 YVORKING HRS.IN ADVANCE fOR=ALL 1tEl3E IREDxINSPEC IONS <br /> Signed x Thle 66 Date _11-00 <br /> SEE SITE MAP IN UNIT 1V WORK PLAN DATED: Litc, -7 19g4 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Is u I��� d D Area 07 5(c <br /> Grout Inspection By Date Z-t'yC F�spe�By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE / PERMIT/SERVICE REQUEST#' <br /> INVOICE <br /> 350 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS'CPWENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />