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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 Floorf 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 San ? <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> Assessor's <br /> WELL Location <br /> Cross Street City Zip Parcel# <br /> i <br /> PROPERTY Owner Address City Zip Phone#. <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH;HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 'Other: WELL# U PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?U YES 0 NO WELL CASING DIA: �I <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: []STEEL U PVC ; O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []',AUGERS OHOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: []Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34) <br /> 0 SOIL BORING U HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> U OTHER: 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,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall emptoy persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> * CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/Company <br /> Print Name Date <br /> SITE FILE ADDRESSIWORK PLAN'DATE:- <br /> ... <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 exp. WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />