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WELL PERMIT APPLICATIONIp•FORM UNIT 1V . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton,CA., 95202 <br /> (209) 468-3445 <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 <br /> San Joaquin County Development Title, !Chapter 9-1115.s and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location 31 y Co ods�c r Q j Cross Street r I c1,—Pa <br /> Assessor's <br /> City�'r u c Zlp 3 1, ParoeI* <br /> PROPERTY Owner A&IJe u vc f Address ' I C)[7 r 7 <br /> City ac zip 53 Phona* �5_ iff <br /> C-57Contractor T AddressCitY� Zip - Lic# Phone# <br /> Consultant 1 Sub TTTT <br /> Contractor -r� N eu Address City <br /> GIS Coordinates:X Y Township Range g Section <br /> WORK TO f3E PERFORMED <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> p WELL# p OVER-BORE <br /> "Other: - AAS�RESSURE GROUT <br /> COMMENTS' SQ.e <br /> TYPE OF WELL 1MSTA U4TION TYPE C�NSTRUCTiON SPECIFICATIONS <br /> ;;MONITORING a HOLLOW STEM DIA.OF BOREHOLE . MULTIPLE CASINGS?p YES ONO WELL.CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICiKNES _TYPE OF CASING: p STEEL $PVC It OTHER; <br /> Q VAPOR a MUD ROTARY. DEPTH OF GROUT'SEAL,'j - ' TREMIE TYPE TO BE USED: <br /> Q AUGERS:. CHOSE <br /> (]AIR SPARGE a RUSH POINT gR0U7 SEAL BUMPED 11 Ya3�+ (]No'IMAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL 80R►NG a HAND AUGER APPROX.BORING DEPTH "�j ::'' ! `°� ` ''` '`"' <br /> `$BOLTED TRAFFIC BOX or a STOVEPIPE . <br /> a OTHER: a OTHER CONDUCTOR CASING PROPOSED?�"�(if YES,list specifications here): <br /> COMMENTS: <br /> lbrfr s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS.ORENCROACHMENT PERMITS ; <br /> I hereby otrtify that I have prepared INS application end that the worX will be donara wit <br /> In a=rdanh, an Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner of licensed agent's signature certirt"thy"tollowlhg:,"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 Cafifbmia." Contractor's hiring or sub- <br /> WORKERS'COMPENSAPON Laws of Califomla a; t a.•.. M Qmpby persons subject t� <br /> contracting signature <br /> APiPL1CA.the <br /> TlIIr,RUST CALL 4$'n bR performance of the work forwhrch this' >rr►ilrs Issued 1 shall ., <br /> M <br /> _ 1N. , K1NC NRS IN ADVA G lr6WALL l;EEQUimi 1N5PECT10N8 <br /> Signed x Tit1e r. ,,.e <br /> Date f <br /> SE' SITE MAP IN UNIT.: IV WORK,,`PLAN 'L7ATED --� <br /> DEPARTMENT USE ONLY] ,r <br /> Application Accepted By <br /> 4Date lssuedyl� , Area <br /> Grout Inspection By f Date ! '� Final Inspection By ' Date " <br /> pestruction Inspection By Date lC�L <br /> COMMENTS/CONDITIONS: S .L` P, .,• ,' '":;u ,: <br /> -� .. <br /> ACCOUNTING ONLY: AIDtJr <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R6C'D BY DATE: PERMIT/SERVICE REQUEST# INVOICE <br /> Cz) S110 3 <br /> C-57 LICENSED CONTRACT'OR.XP SIQN.LICENS� tWORKERS 'COMI'ENSA'l'rUl�i AECLARA:['�O <br /> UNIT IV-6/23/99/sign 66q/mi <br /> • r- <br /> Post-It'FAX Note 7671 Dntelnl]1 �.A P� eeh r�-- <br />