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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 /> l9 (209) 468-3449 ORIGINAL <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 Jo quin Count.� evelopment Title,Chapter 9-h115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> U-( S �er1 VC-A.-,q659 TrIofWTfln/ no p aTHoµNT," Aol10 5 �/ Assessor's <br /> WELL Location Cross Street(AP;f A L Av E- City Loci Zip parcel# OSS../5.:-L5 <br /> PROPERTYOwner Rrz,HAAn (9„K,DFS Address (ut(LI Ct9p,'48LAyq City Ln0-1 Zip9SIL;Zphone Zo`' '567-93G' <br /> +IB AN.H+ <br /> C-57Contractor WiST NAZ- Mr9 1 Address221 F;4-LJV �)p Ro tb City Cc ROt,.,RZip957 Y-1Lic#55Y�Al Phone# 91(,(,3886/3 <br /> A <br /> 6£c LM1 <br /> Consultant/Sub ContractorAc(vflni�E.9 <br /> Address£nv .'arPn yocS N- W(ISnr\ City 3iocKinmLic#b8oZ2I Phone# rY 467 /cnl, <br /> c � lGIS Coordinates:X N,Y ,Township � Range J - Section <br /> WORK TO BE PERFORMED <br /> *W WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> // \\ 0 SOIL BORING# D '7 0 OVER-BORE <br /> $WELL# M W' -- c fn w-° / / %1/ 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> V—NITORING l`D I LLOW STEM DIA.OF BOREHOLE�F-' c MULTIPLE CASINGS?0 YESe0 WELL CASING DIA:_ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5, 1499 R V 0 TYPE OF CASING: O STEEL�VC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS'.r�IcFe ,+OSGTREMIE TYPE TO BE USED: �"UGERS OHOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED:,IK1'es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING O HAND AUGER APPROX. BORING DEPTH `BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? N. (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: "1 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, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> 10� <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN AD NCE FOR A�L'`L REQUIRED INSPECTIONS. <br /> Signed xTitle r QL Z GPLyO Y-Date cy "C <br /> SEE SlTeNZ IN UNIT IV WORK PLAN DATED: a <br /> DEPARTMENT USE ONLY t3 <br /> Application Accepted By Date Issued 3'I.a- Oct Area U,�,.,/ <br /> � <br /> Grout Inspection By Date Final Inspection By !R <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: '� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 5"% 1 CnaA- 3-fo I SR# 696 Z21Z{o <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />