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041 <br /> ,f <br /> WELL PERMIT APPLICATION FYRM UNIT IV <br /> L; R LP SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> OCT 2 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERM4T(SERb;SE <br /> E�VIRC�I.����t�� }��A'Li�i (209) 468-3449 <br /> S <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 Health Division. <br /> nn Cgs71t: 5+ree�j/ Assessor's <br /> WELLLocation e�LIQQ- PAC - AQPAy - Cross Street &;Ci AvCnvtCitySTOLTZ'ron Zip SZ4ZParcel# <br /> PROPERTY Owner VAN Pot n <br /> Address T O. � ) <br /> r� QLI�(Z 7 Cit ST— TPri Zip ?0 _Phone#2Q y(�3 Z I <br /> C-57 ContractorG�F ����r Address !So R� ' City t—Zip YSS�Lig1Phone*q7S_ 13)5-5 <br /> Consultant 1 Sub Contractor ,E, Address 837 v r SNAR c). .City_STc-KTon Lic#&$0Z27 Phone#200. 4107/on <br /> to <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED r <br /> NEW WELL 1 BORINGCPT EOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> OIL BORING# _ OT-1 4 r-P14-2, 0 OVER-BORE <br /> 0 WELL# <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE oQ" MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: A14 <br /> a F-TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AJ TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> O OR 0 MUD ROTARY DEPTH OF GROUT SEAL M TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AH4 SPARGE [PUSH POINT GROUT SEAL PUMPED: gYe � No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH ^eK tfi0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? N1a (if YES, list specifications here): <br /> COMMENTS: C-PTS� <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: "1 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 or sub- <br /> contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> I'✓ORKERS'COMPENSATION Laws of California.- <br /> THE <br /> alifornia,-THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title r o'Lill Date Z A ZC/ D <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: Rlo J\k1 -C;? OQ) _ <br /> EP T ENT USE ONLY 1 <br /> Application Accepted By �'. Date Issued ` <br /> Area <br /> Grout Inspection By Cz Date Final Inspection By Date <br /> ,Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> A }NTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED -CHECK# REC' Y DATE <br /> PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LI O RS' COMPENS ON DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />