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WELL PERMIT APPLICATION FORM UNIT 1V <br /> q <br /> C <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Wever, Third Floor, Stockton;!CA., 95202 <br /> (209) 468-3449 <br /> `i <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 jdescribed. 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 /> l Assessor's <br /> WELL Location Z43.1 E nac•ea;& a V—A- ___Cross Street City Zip SLo Parcetm <br /> I <br /> PROPERTY Owner �.�] CRc�w n� t1t Address 2 f ice, City ti r+ Zip 7.Q 6 PhoneM Z4 g'f1 z�7� <br /> l t 37� �t 6 z�a76 <br /> C-57 Contractor Gia-r 1r. W�k1, k�;Address 267.4 �-4w itr 4 City�,Zipcl � Lic# Phoneme <br /> I { ` <br /> Consultant ub ContractorAU "SN-u1- C-L_Addresstlo t4�.V,41w��r�� cityLicR_Aj�A _Phane#7�q��'I <br /> GIS Coordinates:X Y Township Its Range 11^ Section 1� <br /> WORK TO BE PERFORMED ' <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-SORE <br /> []WELL# PRESSURE GROUT <br /> 'Other: <br /> '� �,�\lS (`hw�1 ave W��•�1 Z. <br /> COMMENTS: LJc_V,V47 +o�n o� l�lve�.• r. <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AiR HAMMERIORIVEN 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 OHOSE <br /> G AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here) <br /> COMMENTS: <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cert'sfy that I have prepared this application and that the work wiA be done in accordance with San Joaquin County Ordinances, State Laws, and Rubs <br /> and Ftegutations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "!certify that in the performance of the work <br /> far which this permi t is issued, !sha!!not employ persons subject to WORKERS'COMPENSA770N Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "!certi.`y that in the performance of the work for which this permit is issued, !shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> C L T E.UNITV INSPECTOR 48 WORKING HRS IN ADJVA CE FOR ALL REQUIRED <br /> /INSPECTIONS. <br /> x <br /> Title/Company <br /> Signed i/ 11 ( �` w <br /> Print NameDate } <br /> SEE S1TE MAP IN UNIT lV WORKgPLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date lssued Area <br /> Application Accepted B ` <br /> Grout Inspection By <br /> 1 Date DD Final Inspection B Date <br /> Destruction Inspecti n By Date <br /> Cpm c,�,.� <br /> COMMENTS I CONDITIONS: ��� C_o I <br /> b <br /> ACCOUNTING ONLY: AID# FArti <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE <br /> PER t SERVICE REQUEST# INVOICE <br /> r <br /> 1/18/2000 <br /> � i <br />