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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD /�• <br /> r <br /> AUG 2 .4 20 01 304 E. Weber, Third Floor, Sto kton, CA., 95202 <br /> NIV <br /> ENVIROENT ''hEA H (209) 468-34 ILL COPY <br /> PER�J1iTlSERVICES f <br /> . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y R FROM DATE ISSUED <br /> Application is hereby made to San Joaquin ounty for a permit to construct and/or install a work described. This application is made incompliance with San <br /> Joaquin County Development Title,Chap r 9-1115.3 and the Standards off San Joaquin ountyPublic Health Services,EnvironmentalAssessor'sDivision. <br /> WELL Location 114 Cross Street t i.� cCity? ZiP Parcel# <br /> PROPERTY Owner �iTy [ _.3 Address 1445 M• 0Vbity ZipcZ3]�/Phone# �© <br /> C-57 Contractor:: � AddresC ty5 �61� ZipgV,25_Ucc##T/2 Phone# q&S�:8 1 2- <br /> Cansultant ISub ContractarTl�I LL_ iyt��_Address 4D -Cityl �Lic�iPhone# C^ '�Y38 <br /> GIS Coordinates: 37a, ,��3 ,Y f!��Z dl 7, �3 ;Township Range Section <br /> WORK TO BE PERFORMED: <br /> ff'NEW WELL BORING(CPT,GEOPROBE,HYOPUNCH;HOD-AUGER,OTHER ) 8 DESTRUCTION(choose type below) <br /> a SOIL BORIN #`� d OVER-BORE <br /> W ELL# 1 PRESSURE GROUT <br /> `Other. <br /> COMMENTS: , <br /> TYPE OF WELL ' INSTALLATION TYPE CONSTRUCTION SPECIFIC A IONS <br /> MONITORING R<OLLOW STEM DIA.OF BOREHOLE Irt MULTIPLE CASINGS? YES 0 NO WELL CASING DIA: Z rl <br /> n EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS5& 4 TYPE OF CASING: j]STEEL [SGC [I OTHER: <br /> Q VAPOR 1]MUD ROTARY DEPTH OF GROUT SEALf TREMIE TYPE TO BE USED: [)AUGERS &ZSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: s p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING []HAND AUGER APPROX.BORING DEPTH I [I BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> OTHER: []OTHER CONDUCTOR CASING PROP SED?�(if YES,list specifications here): <br /> S D S <br /> COMMENTS: ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE S OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in ac rdance 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:'7 certify that in the performance of the work <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'G OMPENSATION taws 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,I shall employ persons subject to <br /> WORKERS'COMPENSATION taws of Califomia." <br /> * C L T NI NSPE T 48 WORKING HRS IN DVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x 1. Title/Company-2. <br /> ~' Print Name d ��(� 1 J�1 )a � -_ Date Z � <br /> S1TE FILE ADDRIr ORK PLAN.DATE: <br /> DEPARTMENT USE ONLY <br /> AreaApplication Accepted By Pip% <br /> 7Grout inspection By Date DatefDestruction Inspection By Dat COMMENTS l CONDITIONS: Z 1, V Will—, ZK V <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RC'D B DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3l � Z � <br /> C-57 exp. WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />