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i <br /> 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 /> i 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> WELL Location �ytl `�r/7+� Cross Street ` ,,, j r Assessor's <br /> r�pp_ ` r rrl0-egg/�, City Zip_ � Parcel# <br /> PROPERTY Owner_+�G(E ���`� Address3(0.7 C'Gt7d ' A)� City / Zip ] hone# Sa 1 L{o <br /> C•57 ContractoA/—tOe `�g> L'—y6(Address 3-2,,S7 r City 916' `'A Zip!L'��kicg��,hone#%qa 2 <br /> r � i <br /> onsultant Sub Contractor Addressers _City�r.# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL I BORING(CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER-) sTRUCTION(choose type below) <br /> 0 SOIL BORING#_h!�Awl eA 7 w�.w3 <br /> E WELL# �"l 0 OVER-BORE <br /> Other: _J3-PRESSURE GROUT <br /> ;OMMENTS: <br /> I-YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> } UIONiTORINGJ}-HOLLOW STEM DIA. OF BOREHOLE f MULTIPLE CASINGS?©YES 01�60 WELL CASING DIA: <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL ePVC o OTHER: <br /> J VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALSF tom( <br /> I AIR SPARGE TREMIE TYPE TO BE ED: AUGERS 21!OSE <br /> o PUSH POINT GROUT SEAL PUMPED: 0 Yes: a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING o HAND AUGER APPROX. BORING DEPTH <br /> OLTI=D TRAFFIC BOX or Q STOVE PIPE <br /> J OTHER:_o OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> :OMMENTS: <br /> L/ Ual <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 /> nd 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 /> )r which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California.,, Contractor's hiring or sub- <br /> )ntracting signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> /ORKERS'COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> n4 95 <br /> igned x l <br /> Title ..—Date a 7 f eD <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> nl DEPARTMENT USE ONLY <br /> opticatian Accepted By L✓ Date Issued_ <br /> �A �(� <br /> rout inspection By rea <br /> Date Final Inspection By Date <br /> sstruction Inspection By Date 3/, <br /> :)MMENTS I CONDITIONS: 60 D <br /> I <br /> ACCOUNTING ONLY: AID# i <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3soa- C'V <br /> 00a1215- <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JIT IV- 6/23/99/sign bkpg/MI <br /> I <br />