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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES [RECE�UFC� <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FEB 1 8 2003 <br /> (209) 468-3450 <br /> ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM Tj <br /> V <br /> f 1�1 ( <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made li h <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 �900fr '.�.Btt&ye�t9^e.ross Street a= City 'p 33C Parcel# <br /> PROPERTY Owner AQ!ke ;. 15C405L{ Address !�J City/� Zip�jJ[Phone# �sJ DO X rj32 <br /> C-57Contmctor U44 Address�.�r y�//���,o City ¢{r Ym, Zip JL4/Lic#72�0yPhone#C/i- 17 -re" <br /> Consultant/Sub Contractor - re tJl/,r.3yCSPCgkl Cit Lic# Phone#�9 8�/SnrG <br /> s <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED XDESTRUCTION 0 NEW WELL i BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) (choose type below) <br /> 0 SOIL BORING# �0,rO.,VER-BORE <br /> WELL# PRESSURE GROUT <br /> 'Other. /� `1 <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS \O <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?O YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE T1 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3l <br /> 0 SOIL BORING O HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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 certifies the following: '7 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." Contractors 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 /> WORKMAN'S COMPENSATION Laws of California." <br /> AP LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Ttle <br /> SEE SITE MAP UNIT IV WORK PLAN. DATED 2-/0-03 49,4,1 <br /> Q. PARTMENT USE ONLY <br /> Application Accepted By �. Date Issued 0 Area <br /> Grout Inspection By V V k Date U Final Inspection By ale 3 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDI IONS: �^0 r�t/ Vi <br /> ACCOUNTING ONLY: AL IF I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#I SH RE I DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3 0Go co SR# R Zs <br /> �-5TACr ESF EOi 1 CTO11-1 SIG#I LIC_ 8 � ©Ml'E1�ISt1TION-DECLr1RALZOL r e <br /> UNIT IV- 6/18/99/sign bkpg/MI <br />