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WELY PERMIT APPLICATION SRM 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,compli nce with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmer`atal Health•Division. <br /> '( j .�j ) Assessof's C", ' <br /> WELL Location !_.._ // Z Crass Street }l��/�r.-Kycity Zip " Parcel#* rn _ <br /> PROPERTY Owner /vf[Jy Address U06„52'__City ��- Zip_Phone# ��YdCJ <br /> C-57 ContractorA"d- l_M Address-! _a/�r ity ip Ck_ is hone# `UUP <br /> Consultant/Sub Contractor Address City Lic# ' Phone# <br /> GIS Coordinates:X Y Township .) Ranger Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE / MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> O EXTRACTION 0 AIR-HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE a-r-ruSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ,P_861�L BORING O HAND AUGER APPROX. BORING DEPTH ' ] BOLTED TRAFFIC BOX or O STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE UORING9 REQUIRE AC SS OR ENCROACHMEhIr P RMITS <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: '7 certify that in the performance of the work <br /> for which this permit is issued,1 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 shad employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.” <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPE=CTIONS. <br /> t� Date /!7� <br /> Signed x � ��� Title Q�i'1� ��O; J <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: -is -gyp <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_—/�i�1La�C_ � Date Issued Area p'7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35301 fob 9P(v C-0 1&12-fr/y 5 Q D tt (7 02 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />