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WELL PERMIT APPLICATION FURM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />.NVIFpNMENTAL HEALTH DIVISION (PHS-EHD) <br />00 JUL -7 304i.NVeber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />,..._ Assessor's <br />WELL Location Lid)16' GO ci*\-ei 100 AS i Cross Street Pru-7 9? City 5.+EX-Lek,KI Zip 5.9-ol 0,.> Parcel# <br />PROPERTY OwnerMar/01,4-4 c)/Viie 0-4-i €9 Address P, 0. bo( so?. Ji city 56y1 g LI& I Zip9V9i5' P honet(ii/c) (/.5 -7..,21S-1 <br />C-57 Contractor _A & Address LOS-A!. (41 ICrAn 1-,-)7 City 5 a, Zip 95)03-Lic#irQ60,-4.17Phone# p,..) W., 7 lar; 6,- <br />Consultant / Sub Contractor 11-6- E Address 14-co5-Ai. cci/se <br />GIS Coordinates: X <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED <br />kKEW WELL / BORING ( CPT, GOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />X, SOIL BORING # 11 14+- <br />9 WELL # <br />a DESTRUCTION (choose type below) <br />o OVER-BORE <br />B PRESSURE GROUT <br />*Other: <br />COMMENTS: 9'y <br /> <br />ity 53-ethi-vkLic# (47O;2 ,PhoneeM +47 .-/e06 <br />TYPE OF WELL INSTALLATION TYPE <br />9 MONITORING 0 HOLLOW STEM <br />9 EXTRACTION 9 AIR HAMMER/DRIVEN <br />9 VAPOR OMUD ROTARY <br />O AIR SPARGE USH POINT <br />r/OIL BORING 9 HAND AUGER <br />9 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1% MULTIPLE CASINGS? 9 YES 45010 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 9 STEEL 9PVC 9 OTHER: <br />DEPTH OF GROUT SEAL},14-re TREMIE TYPE TO BE USED: 9 AUGERS VOSE <br />GROUT SEAL PUMPED: 9 Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 6,49 0 BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? „A/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: "/ 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: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/1", <br />Signed x t/*--: /./V-V-A--Title/Company .).-/-`' f-f 6(26)/ 071 51 <br />Print Name <br />-- <br />B r 11 cevn Al 1 I i i$1 Date 4 a 11 1- 7 - 4)49 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: . <br />DEPARTMENT USE ONLY <br />Application Accepted By 1.1 s'..,..-ti.1 4.- L---,- , Date Issued 7-I ,;/O() Area e <br />Grout Inspection By Lky...v...., ,....-.._ Date -41(t (C(... Final Inspection By I. N-1.4„," 4' L..., <br />D <br /> <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE 15 INVOICE Fthr-T------EETE: .2 CitiSS <br />( SR# 009-N3 ',5- , ) <br />Date <br />/18/2000