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:COUNTING ONLY: AID# <br />FEE INFO <br />8? <br />AMOUNT REMITTED <br />8 7 <br />FAC# <br />REC'D BY <br />co <br />DATE <br />7-/Wryo <br />PER # INVOICE <br />:-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C <br />IT IV - 6/2 3 /99 /sign bkpg/MI <br />E CODES <br />')So I <br />CHECK # <br />RATION <br />)lication Accepted By <br />,ut Inspection By <br />;truction Inspection By <br />MMENTS / CONDITIONS: . <br />Date Z AG'L-c,4 <br />- <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date Final Inspection By <br />- 0 0 Area 0751. <br />Date <br /> <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />)plication 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 />n Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's ELL Location (.e(-)) . tc-ortliCt Cross Street c)ak City Si\--OC l'40n Zip v- (-5 Parcel# <br />(;,,,f1 C Art as4)0 rk/1 tOPERTY Owner Address I OS-0 ,..1 t i t.lc-An. City C)31ockl-CP-N Zip 95-205-PhoneCO-0?)q64-0-d- <br />9C05- /Us (.0114016-7/ city c6k-)-0,, zicRs-gc Lick(40))-7 Phone (/) V6 ? -Na6 <br />57 Contractor Address <br />1 W27 16W <br />insultant / Sub Contractor J'-\ GE- Address itoSp. tuil5an LA)0,7 City S-6,qh Lic# Phone <br />S Coordinates: X Township Range Section <br />JRK TO BE PERFORMED 0 , <br />JEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # <br />a WELL # <br />)MMENTS: <br />ther: <br />a DESTRUCTION (choose type below) <br />0 OVER-BORE <br />PRESSURE GROUT <br />C, <br />PE OF WELL INSTALLATION TYPE <br />/10NITORING 0 HOLLOW STEM <br />:XTRACTION Q AIR HAMMER/DRIVEN <br />/APOR 0 MUD ROTARY <br />\IR SPARGE /r.PUSH POINT <br />;OIL BORING 0 HAND AUGER <br />)THER: 0 OTHER <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2\\ MULTIPLE CASINGS? 0 YES X-1.40 WELL CASING DIA: /1/A <br />CASING THICKNESS NA- TYPE OF CASING: 0 STEEL U PVC Q OTHER: <br />DEPTH OF GROUT SEAL ILvlrif TREMIE TYPE TO BE USED: 0 AUGERS ,f3f-IOSE <br />GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 30' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A/Pr ( if YES, list specifications here): <br />MMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />2reby 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 />I 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 />which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub-,tracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />)RKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />ned x Title SA-a-S-c- 61107(--5-1 Date ,.)-"q -00 <br /> <br />;EE SITE MAP IN UNIT IV WORK PLAN DATED: