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{ FILE CRY <br /> WELL PERMIT APPLICATION FORMS WED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD AUG 2 6 <br /> � 1999 <br /> 304 E. Weber, Third Floor, Stockton, CA., 85202 ENVIRONMEN l L HEALTH <br /> (209y468-3449 Y R4 PERMIT/..SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED ` <br /> Application is hereby made to San Joaquin County for a permit to construct and/Qf 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 /> N� / t Assessor's <br /> WELL Location 7 Q Cross Street r lars. &L — d�O <br /> City Zip�1S 30 ytarCe;# 13 c 3 0 � <br /> PROPERTY Owner jEG_ 1 IIYeS? Add r.,, ',Df_ 2 ( Z City � !!,� Zip Phone# Tr¢! p 3� <br /> C-57 Contractor nr Address`- '� t t J Qyyk 1CitzW_V i_p � �,ic# none# <br /> Consultant I>i�-CQQUae0af hhnl�• �l kar►1 nv ¢ Address r .1>�'� 7. ty �w M r t ir#: Phone#-0 d S�5`c� TJt <br /> r_tc c'onrrlin.aws x �%�� ! 5 _ y�y D r x <br /> .. .�;. <br /> Range sec'wr <br /> WORT(TO BE PERFORMED � <br /> IJ NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,-HAND-AUGER. OTHER') FADESTRUCTION(choose type below) <br /> II SOIL BORING# KOVER-BORE <br /> WELL# 0 PRFSSURE GROUT <br /> 'Ocher. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING a HOLLOW STEM r DIA-00.80REHOLE MULTIPLE CASINGS?a YES a NO WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC Q OTHER: - <br /> Q VAPOR p MUD ROTARY T ;t DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUGERS j]HOSE <br /> a AIR SPARGE a PUSH POINT GROUT-SEAL PUMPED, a Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING p HAND AUGER - .,P APPROX. BORING DEPTH a BOLTED TRAFFIC BOX of Q STOVE PIPE <br /> Q OTHER _II OTHER CONDUCTOR CASING RROPOSED7 (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 /> Ind 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•f shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hiring or sub- <br /> contractrng signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> vvORKERS'COMPENSA71ON Laws of Caiifomia." <br /> THE APPLICANT MUST CALL 48'HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. ' <br /> Signed x Title Date <br /> SEE ITEM IN UNIT IV WORK . PLAN DATED s�il1, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area 0 <br /> Grout Inspection By Date Final Inspection By e <br /> DestruChOn inspection By Date �3 <br /> COMMENTS I CONDITIONS: 66�6t <br /> 4 <br /> ACCOUNTING ONLY: AID# <br /> E1 as <br /> ACCOUNTING <br /> i;; <br /> i <br /> [PE-,CODFS FEE INFO AMOUNT REMITTED CHECKNICASH REC IVED BY*Dq PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Z )!i <br /> G-57 ICENSED.CQNTAGT ORMTST SN LICENSE 8&iY7C7 ',; QMPFN$ TIONEE�ALtATT <br /> UNIT IV-6/23/99/sign bkpg/MI Y <br /> I <br /> Z VtOLI9 1Nb VE=8 6681-9Z—L <br />