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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 /> F <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 Cit 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 Locatiors� lir T� Cross Street ��- � ���Assessor's <br /> Y-- � Zip Parcel# <br /> PROPERTY Owner G�f Address SZ6 I�"A <br /> City Zipy�*Phone# 9rJ �f2 <br /> C-57 Contracto0t k6 Address 6 1'" City D� <br /> i J Jc'so G f <br /> f- P Phone#/� -� <br /> onC sultan I Sub Contractor C-rt1 _Address ��5 N lIU7�/ r I <br /> _ AGity�� ic# Phone'"" /6-7 j661`0 <br /> GIS Coordinates:X Y <br /> Township Range Section l <br /> WORK TO BE PERFORMED <br /> i <br /> I <br /> 0 NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNNCtH, H`ND-AUGER,OTHER-) <br /> D SOIL BORING# DESTRUCTION(choose type below) j <br /> . <br /> 0 WELL# 0 OVER-BORE <br /> 'Other-. ErPRESSURE GROUT <br /> COMMENTS: i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING JYROLLOW STEM DIA. OF BOREHOLE_ -�h � <br /> MULTIPLE CASINGS?0 YES �,�`v0 WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL <br /> � $PVC . 11 OTHER: <br /> Q VAPOR <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL /0 A�1 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> .0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED; Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ]SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH �" <br /> BOLTED TRAFFIC 80X or 0 STOVE PIPE <br /> ] <br /> OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?� �(if YES, list specifications here): <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work wil!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: 'Y certify that in the performance ofthe work <br /> or which this permit is issued, 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> •ontracting 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 /> YORKERS'COMPENSATION Laws of California.,, <br /> THE <br /> A�P�jPLI 'CANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> igned x�ri _u C Title '4W,757' <br /> Date � � <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: `Z7 c, i <br /> DEPARTMENT USE ONLY <br /> pplication Accepted By 17 <br /> _ Date Issued 2 3 O a <br /> Areae <br /> rout Inspection By Date Final Inspection B <br /> Date <br /> estruction Inspection By ��/ Date <br /> OMMENTS 1 CONDITIONS; LO <br /> 4CCOUNTING ONLY; AID# <br /> �E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE f <br /> 00 <br /> oll Ed(o <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JIT IV- 6/23/99/sign bkpg/MI <br />