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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 COW& OPY <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES : YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-11115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location avr7`JS Faaz'�1 A49 Cross +In Assessor's,' <br /> 5<7�-55 y Cross Street�_gtydiy5 A& Zipys3s 7 Parcel# iVd;C?Iic <br /> PROPERTY Owner&V1 ,/Oc41Uiv1 �V'4 Address--City—zip� g plf,! Phone# <br /> C•57 Contractor T r lI', ):µ Address � 'ZT1L2L7`,/ n ciity ZipIT 53 Lig# /G�Phone#c� <br /> Consultant/Sub Contractor l�/ulVb �yirlo Mt 4',Address7 WUt �✓�1 ! City <br /> �Lic# Phone#J'�-&-6-.0 . <br /> GIS Coordinates:X ,Y ,Town;l(iipC V Ran �i&9Z- <br /> 9w Section <br /> WORK TO BE PERFORMED <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> `SOIL BORING#7- <br /> 0 WELL# 0 OVERBORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE9`I mm MULTIPLE CASINGS?D YES <br /> ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSJ!t�2 _TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR ` 'MUD ROTARY DEPTH OF GROUT SEAL-15a-L—TREMIE TYPE TO BE USED: D AUGERS <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 3tYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH ISOSE <br /> S 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 1St) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: t D OTHER CONDUCTOR CASING PROPOSED? /'Lt (if YES,list specifications here): <br /> COMMENTS: '/- 494/71,2r L)/ ISn/hg,� 5j- 6 <br /> "l , 04 <br /> �� C <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: "i certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws 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, 1 shall employ persons subject to <br /> WORKERS,CywOMPENSAM <br /> TION Laws of California." ]( <br /> �1fAC + C ,f':�GURV�' l''i`�II .L� __ 1 �' __I4� po^ .EV.LYSq <br /> Signedz <br /> !!747 �p IF� Lk <br /> Tdle�` ��. 7y77 Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: /khz <br /> DEPARTMENT USE ONLY ' Area <br /> / <br /> Application Accepted By <br /> Grout Inspection BDate Issued r�/3��7 <br /> y <br /> Date Final Inspection By Date <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 /> 351 S� $ 89 535 00 S 1 3 <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> Z d wnH-4 wHnG: II ccc I_ca_>i <br />