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WELL PERMIT APPLICATION FuRM 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 /> 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 /> ivi �,�j� 1 g �,I 1 � Assessor's . <br /> WELL Location ` S" ' irr I /u{,� �� <br /> Cross Streetf� G � 1t City�-`� Glx\ Zip LD Parcel# <br /> ' J' 1 t�6., XZI3 Phone# f,03- �L) <br /> PROPERTY OwnTer,i�'t-e�1(/�'I�,��i%�LI''(.lht,s Address <br /> a �� �����vt&h.l� Pi4�,City S� Zip �1 /� p <br /> C-57 Contractor VVL�T► ft Zi U,65—Address l�v�l Z � lk)ZipC���ic#��-t`1 r Ibhone# �Y�%p'' �l�� <br /> �(lGt c�lL Address I,(,7� CLty ` * <br /> Consultant/Sub Contractor. 't N Std City tsfA Phone# 7 �V- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> W WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )CII0NITORING ,(HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES �/NO WELL CASING DIA: Z it <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALSi4r44e-, TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 56o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH /h er 01-TED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: I <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 Onances at d les <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that <br /> ,�, <br /> e mawork <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of Californi 's h ing or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalp r ons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> //C1AL THE/UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed 1WFd rmw0 96 Title/Company Aoq,! <br /> Print Name �1`f II�Cf�� `"' %�� Date —ZJ J <br /> SEE SITE MAP IN UNIT IV_WORK PLAN DATED: <br /> DEPARTMENT USE ONLY _ <br /> Application Accepted By Date Issued rod Area <br /> Grout Inspection By 1 •'1 Date OC) Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> jj!�LCIO 5R# VOLL-15L <br /> iiisiz000 <br />