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3 WELL PERMIT APPLICATION FORM FILLY <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 2 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 6CI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health <br /> .ss It sDivision. <br /> AsseWELL Location/��� !.✓l � _Cross Streel�i�.�l./a��/1 City Zip 9S�7�1a Parcel# <br /> �— <br /> PROPERTY Owner G'i o7Z a Address�zD Tracy L$/✓� City T� ZIp93�7�a Phone# Ze9 Fes/ <br /> _ i <br /> C-57 Contract rG ! j/i Address 9S f5 �D�t'/LDa^ Ci /SPL Zip9 xruc# 8°�- -A'�Phane# S�/•3.SSD1S <br /> / say9 She zoo <br /> Consultant/Sub ContractoZ,- /.UGC-�4y �/J" rddress�o�-%'f-f h/' 'rCi `I3 (o Z Llc# Phone#2:4 /!01r UIZ <br /> G IS Coordinates:X�a�fT3'• ' �Yl�"0f Township ::�12-5 Rang'--!! SE SecllonT <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) O /'"OVER-BORE(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> 0 W ELL# PRESSURE GROUT <br /> Other: <br /> ,��/Z <br /> COMMENTS: <br /> • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES ONO 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 TREMIE TYPE TO BE USED: 0 AUGERS DHOSE <br /> PAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER:__ OTHER CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certifyt uu I have prepared this applleation and that the work will be done h 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,l shall not employ persons sub/act to WORKERS'COMPENSATION Laws ofCalifomfa." Contractor's hiring or sub- <br /> contracting signature cartillas the following:7 certify that In file performance of the work for which this permit Is issued,I shell employ persons subject to <br /> ING MPENSATIONLawsofCaf mila.' <br /> a CA L THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> ��TklelCompa�ilior <br /> Sign <br /> Print Name -���!/if 'r Date <br /> SEE SITE AP IN UNIT IV WORK PLAN :DATED: <br /> DEP RTMFNT USE ONLY <br /> Date Issued -0-21 a <br /> Application Accepted BY Data <br /> Grout Inspection By Date Final inspection e <br /> Destruction Inspection By Date <br /> COMMENTS ICONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> CHECK/ RECD BY DAEST 9 INVOICE <br /> TE P E REQU <br /> goy a & 55s1 s— Iq b <br /> 5/15/2000 <br /> 60 38tld 800ld H1dId E6068906OZ 61:91 000Z/91/90 <br />