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WELL ERMIT APPLICATION F6rcM UNIT IV <br /> f. <br /> - <br /> -'Z' 5VAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAR 14 2000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENTAL FIEALTH (209) 468-3449 � <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> Assess <br /> or s <br /> ross Street City ip Parcel# <br /> WELL Location A Address City (_1,l Zip 5 �PhoneX3 <br /> 7_$� <br /> PROPERTY Owner <br /> C-57 Contractor di Address Z33 �4�—City ZiV���'�LiVPh �� � X76 <br /> sultant Sub Gontractor /'> t`�� Address �S Al JVJJX&, C;h, Lic �����Phone# 7 /Ub6 <br /> T <br /> GIS Coordinates:X Y Township Range Section <br /> WOR K TO BE PERFORMED <br /> �EW WELL i BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# p OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> *Other: <br /> COMMENTS: C> { z—:: ttt ? rVe 451 StQ�_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,kMONITORING 'HOLLOW STEM DIA.OF BOREHOLE/V-t'&4 MULTIPLE CASINGS?JJ1fES 0 NO WELL CASING DIA:Z M <br /> 0 EXTRACTION 1]AIR HAMMER/DRIVEN__ CASING THICKNESS gO,OZ TYPE OF CASING: p STEEL_�,, PVC D OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL c:?Z>r'fD ' TREMIE TYPE TO BE USED: ,g-AUGERS OHOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: A]Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH /lD f 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> a OTHER: p OTHER CONDUCTOR CASING PROPOSED? &Z6: (if YES, list specifications here): <br /> COMMENTS: <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: "I certify that in the performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signatdre certifies the following: "I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to . <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED 1NSP.ECTIOIVS <br /> Signed x [iC_ _ _Title/Company <br /> r I <br /> Print Name �I�� �� � - -✓��T((� Date <br /> SEESITEvAAWK 1JNiT,r 1V WORKPLAN DATES77 <br /> f�,. -. DEPARTMENT USE ONLY <br /> Application Accepted By � IUNM( _ Date IssuedArea <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 /> i <br /> SR# <br /> 16D _ 1?,7gr blo�5f�5� <br /> 1/18/2000_ <br />