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WELL--ERMIT APPLICATION FARM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> GOT 2 4. ZOJ1 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> r (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 compliance with <br /> San Joaquin iCp1unt Developme t Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 1 '�l]'a ,V <br /> ,S S �L Assessor's <br /> WELL Location oro - Cross Street Ayroro- cityyl'oC{C 3y1 Zip Parcel# 134=fid 48 <br /> PROPERTY Owner S Address 400 (iolckyi SHom City Lori e,&cti Zipa O?02- Phone# <br /> C-57 Contractor -t F�►Vt.ov�trr►0n1 Address 39q Sheri 4 �Ia� y b83$65 uo?) <br /> j� city�Zip�5Z5L Lic# Phone# 7- ; -357o <br /> erv�tes t�� zoh) <br /> onsulta /Sub C ntracto<ov%Jor Ea f-Wrec)kno(o�ddress 197 P=a.••K weSrnt�(Cityc3t ekor. Lic# hone#,23ct-0 S-( <br /> U�lt 3 Y <br /> 1 ui L <br /> GIS Coordinates:X Y Township / /Vdr7 n Range (/o r--t t Section <br /> WORK TO BE PERFORMED <br /> OEW WELL/BORING(CPT,GEOPROBE, HYDROP,UNCH, HAND-AUGER, OT ER") a DESTRUCTION(choose type below) <br /> J"SOIL BORING# -t- A 0- 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> `Other: C r' <br /> COMMENTS: $� �(( -1-1�o r�' S ' reSSury rolrh o tke $Ur oc <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH '75 �fmt 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: OTHER ;e _ CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> IF <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T APPLICANT UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title �rrn hya„Q�ecce&Xca(oate 214 +a$e <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED Qc*b6e - -3 , aoa[ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Z/o 16 / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 35 I gq • ?DSR# �—' <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> C',s s <br />