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a 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 <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 0-1115.3 and the Standards of San Joaquin County Publle Health Services,Environmental Health Division <br /> WELL Location 7 West \� ' Cj}cw� Cross Street 011 "'Mol City�c*��.., 2 p P AssessorrsSarJo•_ 'o1w•o} <br /> PROPERTYOwiner ECc>r+Y\ r.fl�. - Address��`( W=A- �1"` Cj},.,,,-k city „„ zip l6Phor,ea 'D35-2-H <br /> G6T Contractor V W r1�c,.�t:.,,0 Address pXi. LAI �1b0 <br /> ^onisultaiic SubCotmaaor_- Address__. _ C City Lith Ptrontax <br /> GIS Coordinates:X Y Township a J Range 5 E Section �t0 <br /> WORK TO BE PERFORMED I VPR\co p NEWWELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER? 010ESTRUCTIhoose type below) <br /> 0 SOIL BORING#0WELL# ESSU RE <br /> 'Other: ESSURE GROUT <br /> COMMENTS: <br /> TYPfi OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?u YES U NO WELL CASING DIA <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL p PVC (I OTHER, <br /> U VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0140SE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: u Yes 13 No (NOTE.MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> a OTHER: f1 OTHER 0 BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CASING PROPOSED? (if YES.Oct specifications here): <br /> COMMENTS: Morr. ^ea '`wc��9 <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 Joaeuin County. Homr:ownor or licensed agents signature anmes the following:%Certify that in the perforrawre of the work <br /> for which this permit is isaaea I Shall nor employ persona strbjeM to WORKERS'COMPMA17ON Laws of CvftmW Contractor's hiring or sub <br /> contracting signature certifies the following:'I certify that in the perlbfmanCB Of the cacti for which this permit is issued,!shall empty parsons subject to <br /> WORKERS'COMPENSATION Laws of Cafifonria," <br /> Aa <br /> LC'. [(kr I r'�V+ ' I .:+18 .k A /AD5N41t14:E''i"E71Ii}y�1 �EaiRED%iA1�Ik+lI�S: <br /> s geed x — (_ _ 'q TitlatComp9nY �1 '�i e f C e In vx i e 'i� <br /> Flint Name v (� v.� i t Date > Z Q <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> Grout Inspachon By Date Fina;Irwpeetion By Dam <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE MFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE RE12UEST# INVOICE <br /> 1118/2000 <br /> TOTAL P.02 <br />