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I hereby certify that I have prepared this application and that the wont will be done in accordance with San Joaquin County Ordinances. Staie Laws, and Ruleo---, — <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 WORKMAN'S COMPENSATION Laws of California." <br />Contractor's hiring or sub- <br />contracting signature certifies the following: -/ <br />certify that in the performance of the work for which this permit is issued. 1 shell employ persons subject to c ) I <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> WORKMAN'S COMPENSATION Laws of California." <br />Signed x <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />/770///yeeate /0/C/99 Title <br />ACCOUNTING ONLY: AID* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/CASH <br />33-0 I . 00 <br />PERMIT/SERVICE REQUEST NUMBER DATE <br />9-22-1999 4:00PM FROM <br /> <br /> <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />UNIT IV <br /> <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 />i - Assessors <br />WELL Location ggO V;c4ok ,S+1^e t•-{ Cross Street Be-c. bran.. City /. (p c( i Zip Parcel# Oift7-05-0 -3R <br />S v:1 e 20 sr, 0 he 5Aell Pla.2.4. <br />PROPERTY Owner Eth-ioe En-ify..-s. C-LL Address 9 ID Loa; s : 6, net -S•ft-te4. City Hays-10h Zip 77,00.2 Phone# <br />C-57 Contractor 6k.e5 9 Dk.:11:ni Address /SO Ho k1. P d. . City Mot I- 1-: he? Zip9 q553Lic-#Y1GIL 925 S Phone# ,-•31, .3„a <br />Consultant/Sub ContractoreALmb v.a. ,n v; ven otedatAddress 2 70 Pe.i-le•-%.)3 .5 -r <br />Section <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED • <br />NEW WELL / BORING (OPT, GEOPROBE. HYDROPUNCH. HAND-AUGER, OTHER-) <br />%sou_ BORING # 6P-3 <br />AwELL# min/ - +L.-t',vv W - <br />a DESTRUCTION (choose type oelow) <br />Q OVER-BORE <br />Q PRESSURE GROUT <br />Cy .5o no pia Lic# Phone# 707- 93C-4/€7•S-0 <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />%MON ITOR I N G It HOLLOW STEM <br />a EXTRACTION El AIR HAMMER/DRIVEN <br />VAPOR MUD ROTARY <br />El AIR SPARGE El PUSH POINT <br />X SOIL BORING HAND AUGER <br />j OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DA. OF BOREHOLE, 7 - 1ne.1, MULTIPLE CASINGS? Q YES fr NO WELL CASING DIA:g„..,4 <br />CASING THICKNESS,It- ;nc 1., TYPE OF CASING: El STEEL PVC a OTHER: <br />DEPTH OF GROUT SEAL 410 TREMIE TYPE TO BE USED: a'AUGERS CHOSE <br />GROUT SEAL PUMPED: Ill'Yes a N. (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 5-5-fLr OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />4 e714,Date Issued /0/ / 3 /W Area 3O I .70EPARTMENT USE ONLY <br />t Final Inspection By Date <br />Destruction Inspection By <br /> Date <br />COMMENTS / CONDITIONS: <br />Application Accepted By <br />Grout Inspection By <br />FAC# <br />INVOICE