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WELPERMIT APPLICATION FIRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEF � ". <br /> = ENVIRONMENTAL HEALTH DIVlSLON.(PHS-E <br /> WED <br /> 304 E. Weber, Third Floor, Stockton, CA. 95202 <br /> (209) 468-3449 JAN 0-7 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSl3EI�' �� !�iL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This t#o i nce with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Se s,Envirronme�nta�th Division.' <br /> WELL Location 5 3 5 V . Assessor's <br /> v!i p�? S Z_ Cross Street 0 u 1< 51- City S L t i f b-1 Zip R S7-0 h Parcel#_f 5 I �YO ?IL <br /> PROPERTY Owner i-RL,1 9 F� v ro U Address o• Pct 6 City M�>r c-J Zip—!L3±y 3V Phone# -3 f"G q 5 5- <br /> C-57 Contractor ll Uvu�•� (,•� vvira:z,uAddress 460o N- W)15011 Lv.y City 5ro rllik5'1ZipQ5�G9 Lic# Sb;-;-Phone# 146.7`10(1�j <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township - Range Section <br /> WORK TO BE PERFORMED I <br /> i <br /> 0 NEW WELL!BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> .SOIL BORING# <br /> 0 WELL# - 0 OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: i! <br /> TYPE OF WELL INSTALLATION TYPE, CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE <br /> �_MULTIPLE CASINGS? 0 YES H NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL. 0 PVC 0-OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T TREMiE TYPE TO BE USED: 0 AUGERS. OHOSE j <br /> 0 AIR SPARGE APUSH POINT GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IKSOiL BORING 0 HAND AUGER APPROX.BORING DEPTH D 1 -a BOLTED TRAFFIC BOX or 0 STOVE PIPE I <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? V (if YES, list specifications here): <br /> COMMENTS: fVC ']r�tom � <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 licensedagent's signature certifies the following: "I certify that in the performance of the woik <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 signature certifies the following: 1 certify that in the perfprmance of the work for which this permit is issued, I shall employ persons subject 10 <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> 1/' <br /> // ,�THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL, REQUIRED INSPECTIONS. <br /> Signed x 42: -� jc / Title tp- l?e 0 1 a ,'5 l Date J. 7/OO <br /> SEE SITE MAP I UNIT IV WORK PLAN .DATED: rz I�QY I �q f <br /> Application Accepted By ��'�*Date <br /> .DEPARTMENT USE ONLY �� � <br /> Date issued 1 4 Area <br /> Grout Ins ection B 1 <br /> p y ate final Inspection By Date <br /> Destruction Inspection B <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE - PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LI NSE &WORKERS' COMPENSATION DECLARATION " <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />