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ORtBiNAL <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 344 E. Weber, 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 /> l 1` i_d City _ <br /> 11-% 11•C 9 Ce.1,W Cross Street I ` 1(eA1 ice" Zip� 7� Parcel#Ct a <br /> WELL Location _ j <br /> C AddresOol; 1t� i. City Ime Zip 173A Phone# (?6g)93)- `!e0 <br /> PROPERTY Owner L�,�, <br /> G-57 Contractor s� a[ ^1 �1 Address 3�3� oM¢G CtKCity 10 <br /> 4 Cva Zip4 �`�ZLic#71� IQ Phone# 16– 6 10 <br /> Consultant 1 Sub Contractor C�-R �Address 3164 (1,111S G V.-—W1 City a Lic#_5S71 Phone# <br /> G15 Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER') Q DESTRUCTION(choose type below) <br /> 0 OVER-BORE <br /> a SOIL BORING r d PRESSURE GROUT <br /> `%]HELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAPIONS <br /> MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: 2 <br /> j�MONITORING (gIiOLLOW STEM DIA.OF BOREHOLE__ VC OTHER: <br /> G EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sc� q(> TYPE OF CASING: STEEL <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL____3_�__ <br /> TREMIE TYPE TO BE USED: 0 AUGERS DHOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: o Yes *(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> APPROX. BORING DEPTH i's r <br /> `;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D SOIL BORING [}HAND AUG/=R <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> a OTHER, 0 OTHER <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 certifie s the following: "I certify that in the performance of the work <br /> ns subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> far which this permit is issued,!shall not employ persocontracting signature certifies the following: "I 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 /> T A PLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 71 Title �� �o C�7e�� 5 Date I0 11 Ob <br /> Signed x <br /> ff SEE SITE MAP IN UNIT IV WORK PLAN DATED: GG 1 r 13 Zcuz) <br /> DEPARTMENT USE ONLY / 60 <br /> Date Issued ear <br /> Application Accepted By '"' pea <br /> Grout inspection By <br /> Date Final Inspection By tem <br /> Destruction Inspection By Date2-4 A4 <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE�E T# 1NVOlCE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-5/23/99 /sign bkpg/MX <br />