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x <br /> WELL PERMIT APPLICATION MRM ' 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 /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to constrict and/or install the work described. This application is made in compliance with i <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division... <br /> I Assessors <br /> WELL Location vgl _r� _Cross StreetScCity 'Zip 9s ZkaY Parce#r <br /> �111vU �, ? j kS Zip�l� �7 �5 <br /> 'PROPERTY Owner {- '""" ..._Nao�ss CiPhone <br /> n�i�/�� ,. <br /> C57Contra ctor 'T� /lcg�_ Address �3f\� Cityi�Zip'9- rii � Phoned /(Z6O <br /> Zcg <br /> q7 � <br /> Consultant/Sub Contras LSAddress8 City <br /> - CAI <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> n NEW WELL I BORING(CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') ESTRUCTION(choose type below) <br /> 0 SOIL BORt $ ,,.. . Q OVER-SORE <br /> kt*AJ-)0 WELL# rl _ j RESSURE GROUT <br /> 'Other: <br /> COMMENTS, Y <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �LLOW STEM DIA. OF BOREHOLE MULTIPE� CASiNGS7 Q YES � NO WELL CASING,DIA: <br /> r TRACTION HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: aSTEELVC Il OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 2KCSE <br /> 0„IR SPARGE a PUSH POINT GROUT SEAL PUMPED, (]Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (j S5IL BORING 0 HAND AUGER APPROX. BORING DEPTHBOLTED- <br /> _ RAF-FIC SOX or Q S30VE PIPE" <br /> OTHER: CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: s 6 <br /> C <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> f hereby certify that I have prepared this appiication and that the worn will be done in accordance with San Joaquin County Ordinances, State Laws,and Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "f certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> ontracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued.,I snail employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Ca/ifomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> AqSigned x Title � J Date /2/ Z ) <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> 1tG� <br /> DEPARTMENT USE ONLY <br /> Application Accepted Sy -- Date Issued - Area LSP +d01 <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> 'L <br /> FAG# <br /> ACCOUNTING ONLY: AID# I <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICc <br /> tom- do z-r S6 <br /> UNIT TV- 5/99/MI I <br />