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WELLPERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> Weber, Third Floor, Stockton,IlIlnCAH95202D) <br /> 3 4FILE COPY <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Applicat on 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 Joa juin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> / AV7Jir <br /> G Assessor's <br /> WELL Location 20Zs �V• ry C� frfir��,�C�roosss Street �1 City./ V— Zip Parcel# <br /> PROPERTYOwner 7�1�'� � rR7tIIC>'adarL'�s�FAN/SL4a-�.lp(G�o„f�l City lire Zip Phone# <br /> C-57 Contractor,40161,1zem (7l/l/JF�tu/rCNME y�r A/ GW4Sal/ City 11 O.r Lic# ?6 Z,;phone# V4714'd <br /> Consultant/Sub Contractor SihME Address City J9&0I - LicitL:L6�7Phone# r f <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDR UNCH, HANDJ� OTHER-) p DESTRUCTION(choose type below) <br /> g SOIL BORING# -I C OVER-BORE <br /> C WELL# C PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C MONITORING C HOLLOW STEM DIA.OF BOREHOLE 4" MULTIPLE CASINGS?C YES C NO WELL CASING DIA:= <br /> C EXTRACTION C AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: C STEEL C PVC C OTHER: <br /> — <br /> a VAPOR C MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> C AIR SPARGE C PUSH POINT GROUT SEAL PUMPED: p Yes C No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER APPROX. BORING DEPTH I�X/D r C BOLTED TRAFFIC BOX or C STOVE PIPE <br /> p OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS:— �.Q7 - Sir/Z�CK7OW/&hi-c- 51—(eg — /ANO A16*r— 1iV AdlwOZ <br /> UeT <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: "I certify that in the performance of the work <br /> for which this permit is issued,I 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 employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICANT MUST ALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed TitleVIA-� Date 3//O lJ <br /> SEE SITE MAD I UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted BDate Issued _ _�V Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> A/1522_553 ( 2 Z9 0v� <br /> C-57LIC ED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />