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�REv_ �vw WELL PERMIT APPLICATION FJRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> OCT 2 5 2000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRON�M�SERV� ES tB04 E. Weber, Th`0) 468-344grd Floor, kton, CA., 95202 <br /> pERM <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 County Development Title,Chapter 9-1.115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> rr .1� ' 1 Assessor's <br /> WELL Location Iu��5 S WL��ur� S T Cross Street ell-)Ifki CityLoj / Zip Parcel# 6&;l 'OS 3 <br /> PROPERTY Owner R-)664 /VO VI Address /v� City Zip I A Phone -g <br /> C-57 Contractor Pre,,-I S IOrt 1"PI Address 1%) S . 50 5) CitA( VIM Zip/QIYK Lic#/�, 3�7 Phone# ' 1 3 7 -YS 7' <br /> Consultant/Sub Contractor AG-J AddressgoS/U X150-n .aYCitySTGU�^ Lic#CXJJ7 Phone ��l <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 6EW WELL/BORING(CPT, 9EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# B V 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a„ MULTIPLE CASINGS?a YES;BNO 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 En}i�"e TREMIE TYPE TO BE USED: 0 AUGERS -)QflOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED:.�es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Of <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? t/A (if YES, list specifications here): <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, l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICANT M S CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed <br /> Signed x Title�S2,010S/ -5 Date Iv � ay <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r, Date Issued 10/3 l r00 Area <br /> Grout Inspection By IAt�16 , C,.-, Date Lk It OO Final Inspection By Date ( �C) <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMI S REQUEST# INVOICE <br /> O 1 0.00 t lob sg# ooAq z.o <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />