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r • FILE COPY <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 FEB - 9 Mi <br /> (209) 468-3449 <br /> ICI'� f1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIFcMfl,�� <br /> Application is hereby made to San Joaquin Count for a permit to construct and/or install the work described. This ap rvices. Environmental <br /> n iro�fpj�9 l Heal !ate with <br /> App y y fi <br /> San Joaquin County Development Title,Chapter 9 1115.3 and the Standards of San Joaquin County Public Health Services, Envi Assessor's <br /> oa vision <br /> WELL Location f dr Cross Street So,;,'0��3 sTCityS eC�r� ZiP <br /> Parcel# f37-jf-/y�ll//L <br /> Address S17 C� %fes- Si• CitySIZY eTdn/ Zip Phone#Z/3S- �4zle SWT <br /> PROPERTY Owner EGGS L�+/��� <br /> Cit 41AA062,r Zi Z?4, Lic#6Zf,adPhone#6KCcr 00l 9 // <br /> C-57 Contractor w-••=��'�' �,�i,c-,c,in,•��Addressp��.3-)u 141'6Yom- p <br /> Consultant/Sub Contractor <br /> Address City Lic# Phone# <br /> GIS Coordinates. X <br /> Y Township A10AL.-I-4 Range r% LA5f— Section4/W //,/ L <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL BORING CPT. GEOPROBE,grEE�D <br /> HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below' <br /> 0 OVER-BORE <br /> SOIL BORIN0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> COMMENTS: 7D le ZIA <br /> TYPES INSTALL TION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM <br /> DIA. OF BOREHOLE �� MULTIPLE CASINGS?0 YES ONO WELL CASING DIA. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 AIR SPARGE O PUSH POINT ') <br /> HAND AUGER APPROX. BORING DEPTH �O /J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> SOIL BORING D <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 0 OTHER:�._0 OTHER <br /> .,1- � ,ti• v r� <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lawof s. and Rules <br /> or licensed and Regulations of the San Joaquin <br /> l shalt County. Homeowner <br /> employ persons subjecttonWORKERS COMPENSATION Laws of California."t's signature certifies the following: "I certify that in Contractor's hir 5 0�S work <br /> for which this permit is issued, <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject o <br /> WORKERS'COMPENSATION Laws of California." <br /> C L THE U T IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company 1Gc*,�/�e� lJ.�/GGiitf�i f <br /> -'Signed x <br /> IA/ <br /> / 7 Date Z 9 • o <br /> Print Name YA <br /> SEE SITE MAP IN UNIT lV WORK PLAN DATED:: L:4 <br /> DEPARTMENT USE ONLY <br /> Date Issued Z —/Z Area-------- � <br /> Application Accepted By Date_�� <br /> Date Final Inspection By <br /> Grout Inspection By <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/SERVICE REQUEST#. INVOICE <br />