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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br /> �O� �J 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> v (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 Oivisicn <br /> I l l J /1^� ( G Assessor's `1 _ <br /> WELL Location WLR' n0?1 111 Cross Street G�, I4 City rCA�'� Zip 15 DG ParcelTM �/�-q7`�6 OOy <br /> PROPERTY Ownerlofv� ce LVS I+Z Address�,�7 Wr keMer m City�1�C/y} _Zip%Phone: 0 y J ��/O <br /> C-57 Contractor AlfL AddressyC275/y �"iso0 �.lkiy city M Zip V Lic#. ZPhoneR )��71G <br /> Consultant/Sub Contractor_ -AGE Address q00 �t L 1 t li56n L ity S r Lic966QA2PhoneQQih--/6-7 -rva6 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> iGEW WELL/BORING(CPT. GEOPROBE, HYDROPUNCHp, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> )'SOIL BORING# P I f S_ 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,� / <br /> lf <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE -D" MULTIPLE CASINGS? 0 YES �O WELL CASING DIAlt/ <br /> 0 EXTRACTION 0 AIR HAMrv1ER/DRIVEN CASING THICKNESS_TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> 0 AIR SPARGE �USH POINT GROUT SEAL PUMPED: 0 Yes �io (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER APPROX, BORING DEPTH �7y 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:-o 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: "I certify that in the performance of the work <br /> for which this permit is issued, /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 California." <br /> CA L THE UNIT IV IN CTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED NSPECTIONS. <br /> Signed x - Title/Company l <br /> 11> _< r I�/!'1G3V1 Date <br /> Print Name i i �In <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY q 45U <br /> Application Accepted By <br /> Date Issued zz/00 Area <br /> Date. 3Q �D Final Inspection By Date. <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 6' <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEDj;j REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3� l.� if zz p o Z3 75 <br /> 1/18/2000 <br />