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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEVECE ED <br /> ENVIRONMENTAL)HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber,`Third Floor, Stockton, CA., 95202 JAN 2 2 2002 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> WELL Location 2 N. SUTTEI? S 77 Cross Street-/,7/NE2Assessor's <br /> City S%OGfe(0L( zip,?-6'2-02 Parcel# 1399-2_ <br /> PROPERTY Owner SVTT1,? pFF/CL CEN Al s 2 o D/ //,y/o^1 5 T� <br /> X110 res - s A a�itySA// G,e.41V- ZiP?//2.3 Phoner(�/s� y�J7-6� z <br /> C-57 Contractor_V C Ra r(EX <br /> Address 7 CitZip9_y�ic#705-927 Phon <br /> Consultant/Sub Contractor f/J�/',e o Address/' ,FOX `113-3 <br /> City/'7%. Phonet{6 S v�c�2g-O Sgt <br /> GIS Coordinates:X , Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) <br /> 0 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> 0 WELL# 0 OVER-BORE <br /> 'OtheACTPutty R / iPRESSURE GROU7COMPCNTS p ./Cq/ CF ,1N-PI G <br /> " ee0RO*/VCE <br /> wrrN <br /> TYPE OF WELL Ne /4PP,PovEID WOiefc PL14 — S, Tr corer 3ZINSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '? <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE / " MULTIPLE CASINGS? YES <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSVNO WELL CASING DIA: <br /> Q VAPOR 0 MUD ROTARY TYPE OF CASING: O STEEL p PVC p OTHER: <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: 0 AUGERS OHOSE <br /> p SOIL BORING 0 HAND AUGER 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX orSTOVE PIPE <br /> *-OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS:_ ,, yf3ES To Jar Stf}cED j," -6 <br /> o 1 ,q r -Lv ,4F I c/Z .L9.•,PL/row <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will Ye 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 /> THE PPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x H yj)�p G EOLC,6 f$�- Date_1 16 O t <br /> Title / <br /> SE ITE MAP IN UNIT IV WORK PLAN DATED. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By__��_yam. M <br /> Grout Inspection By Date Issued / d Z Area <br /> Date Final Inspection By —�--�— <br /> Destruction Inspection By Date z � <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ----------------------- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# tREC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> iso � C0r <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKS 'z �J O �� 3 <br /> UNIT IV- 6/23/99 /sign bkpg/MI RSCOMPENSATION DECLARATION <br />