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WELPERMIT <br /> APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE , <br /> -�E - , . <br /> ENVIRONMENTAL HEALTH DIVISION (PHS >. ., I ' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ' EL) <br /> (209) 468-3449 JAN 0 7 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IMj6R0NMENTA[- HL-ALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi t90 i r nce with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Se cies,Environmenntalealth Division. <br /> A/ - Assessor's <br /> WELL Location <br /> u I D vi S Z_ Cross Street 6 a_l< S�- City 5 o c k)e)J—ZiP 4 s7'a� Parcel# LSI— 0 <br /> 80'-2� <br /> PROPERTY Owner R400 F e wro Ir p <br /> Address a• Fol 7-364 City t!e✓—c -i Zip Qti 3y Phone# 3 S� "Gq j 1,- <br /> C-57 Contractor AJvo ir- oNW,1odrBss � <br /> I/t/aS d r <br /> City fi ✓1Z09L— Lic# f,0�- "7Phone#-g67"!O61� <br /> Consultant/Sub Contractor Address City Lit# Phone# i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> I.SOIL BORING# 21 <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS' <br /> J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE <br /> �_MULTIPLE CASINGS?0 YES B NOS WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 6 PVC Q OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T- F TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE APUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> D;SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH_ Q O BOLTED TRAFFIC BOX or 0 STOVE PIPE,; <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? V (if YES, list specifications here): <br /> 1� J <br /> COMMENTS: fVC jr,toA W i-R i i T <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: `7 certify that in the performance of the work i <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 APPLICANT MUSTICALL 48 WORKING HRS IN ADVANCE FORA LLRE`Q' UIREDINSPECTIONS: <br /> Signed x /[.c / Title ZP' l?e a f c9F 1`5 r Date f 7/00 i <br /> i <br /> SEE SITE MAP !IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY l �y�.,� <br /> Application Accepted By s dYL Date Issued o ` w`� Area 35 07 <br /> Grout Inspection By Date Final Inspection By Date - <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK <br /> # RECD BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> S/I t �p 2 3 <br /> C-57 LICENSED CONTRACTOR MUST.SIGN LI NSE &WORKERS' COMPENSATION,DECLARATION.: 4 <br /> UNIT IV- 6/23/94/sign bkpg/MI _ <br /> _..... <br />