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r <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAIF JOAQUIN COUNTY PUBLIC HEALTH SERVICES--,' <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-E , <br /> J _ <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520 ,, /? p <br /> (209) 468-3450 1: 39 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE C <br /> Aoplication 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 /> WELL Location //��� // I Assessors <br /> ' �' .��Gt- 1� II(�su� Cross Street�vL�l�tL City �'�C -,Tr Z'ip'�Parret# <br /> PROPERTY Owner 141 r�1 fa41PQ R--e-"tom kSAddress /�d V y afj City FOeWd 61 p 95-231 Phonal 19&Z-0)Z l <br /> ---7 Contractor �/ �l Address ,�Cl� S� City. r''01,4�5 ZLzip #5 Lics?2o%&­/Phone*q1.1'777-wco <br /> Consultant/Sub Contractor yyr lGii Address get f City �K+�'�LieA 5y7S� Phone# � 36V <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> lt�vEW WELL!BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> a SOIL BORING: a OVER-GORE <br /> PRESSURE GROUT <br /> 'Other. --- --- - <br /> COMMENTS: <br /> 'YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICA TIONS r/ <br /> ] IMONITORING )•HOLLOW S TEM OIA.OF BOREHOLE 9" MULTIPLE:CASINGS,?a YES `60 WELL CASING OtA:2 <br /> < t0_XTRACTION a AIR HAMMERIORIVEN CASING 7 HICKNESS 10 YC' TYPE OF CASING: a STEEL Jr /C a OTHER <br /> a VAPOR a MUD ROTARY OE.°TH OF GROUT SEA! /Z 7REMIE TYPE TO BE USED: JAUGERS CHCS: <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> a SOIL BORING a HAND AUGER APPROX.BORING DEPTH '27 Jk/3OLTE0 TRAFFIC BOX or a STOVE PIPE <br /> 7 OTHER CONDUCTOR CASING PROPOSED' I /UO r if YES. ,st specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i nereby certify that I have prepared this application arta that the wont win be done in a=raance with San Joaquin County Ordinances,State Laws,and Rwes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agenCs signature certifies the following: "I certify that in the performance of the work <br /> for this permit is issued,I snap not employ persons subject to WORKMAN'S COMPENSATION Laws of California.- Contractor's hiring or sub- <br /> which=ntracing signature certifies the following: It car*that in the performance of the work for wnich pus permit is issued I snap employ persons subject to <br /> 'NORKMAWS COMPENSATION Laws of Calffomia.- <br /> E APPU ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ( <br /> Signed x TitleDate <br /> (co, tc:,.� <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED f Ski/•o� <br /> DEPARTMENT USE ONLY O Q —Area � <br /> Application Accepted 8y Date Issued (Q 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: W d <br /> FACS <br /> .ACCOUNTING ONLY: I AID# <br /> I <br /> PE CODES FEE INFO I AMOUNT REMIT' DI CHECKSICASH RECEIVED BY DATE r: PERMI715ERVICE REQUEST NUMBER INVOICE <br /> 00 i E <br /> EA <br /> 23/O2.-. <br /> UMT IV-5/99/MI <br />