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WELL ERMIT APPLICATION FORM <br /> UNIT IV <br /> MD <br /> 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESF � E" " `— <br /> UN 2 6 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JUN 2 3 2000 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 Qp <br /> (209) 468-3449 E114"PERMIT/S ES H <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> - <br /> '/ / / Assessor's <br /> WELL Location Il7iq W'/YdSL1 l;460 Cross <br /> /Street 'Jeff/514, . City Q 'G zip Parcel# y <br /> PROPERTY Owner f nl/''//(i!'R,4/l Address <br /> /4W W'�70�-J 1"r!✓ City /�41 A✓ ZipjS��PChone#/'41r3—/0o3 <br /> C-57 Contractorf��a L�'/�!A_�- / /A�ddre/ss 3Z Y[ l/�.�"`t r"� Cit a ''"Zi� kic#7'7 rRhone#�i' �7/Z16 <br /> Consultant/Sub Contractorfi"ma 17P�'GIw Address Y[lJ.�/`r'W�� "'1t:ily 'SlOe4l�l Lic# Phone# 47-/x(a <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> P EW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) O DESTRUCTION(choose type below) <br /> O SOIL BORING# 0 OVER-BORE <br /> §y0ELL# kdW —�/L!W_ 0PRESSURE GROUT <br /> 'Other: '" <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING phfbLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES �JO WELL CASING DIA: Z�r <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS%# O TYPE OF CASING: O STEEL ),PVC O OTHER: <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEALS_TREMIE TYPE TO BE USED: GAUGERS OHOSE <br /> O AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: -Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING O HAND AUGER APPROX.BORING DEPTH / kSOLTED TRAFFIC BOX or a STOVE PIPE <br /> O OTHER: O OTHER CONDUCTOR CASING PROPOSED? AJ if YES, list specifications here): <br /> COMMENTS:- -6eM/ r l�:5�/ <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: "1 certify thatin 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: "1 certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> I <br /> HE IQI SPEC R 48 WORKING HRS IN ADVANCE F R ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> Title/Company f /0Print Name ✓�1 ✓'�' Date�17i51�� <br /> SEE SITE MA IN UNIT IV WORK PLAN DATED: <br /> /`} }/�j�{),,/DEPARTMENT USE ONLY <br /> Application Accepted By ; 'Z `�I" "" nDate Issued <br /> Grout Inspection By ate CJ inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMEN I CO DIT NS: <br /> S <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY DAT PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 Pal f Q � �d ? 023 2 } <br /> 1/18/2000 <br />