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1 <br /> WELL PERMIT APPLICATION FORM 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 Count D velopment Title,Chapter 99 .3 an the Standards of//S''an Joaquin County Public Health Services,Environmental <br /> I Health Division. <br /> Cro s Street (tl cry11A City _Zip 9S20?- Parcel#Cl %,0k$4pc.� " <br /> WELL Location `�.p�,� <br /> LL�� II �rl'�O c5-40 c-. rnw ��=Ip'Phone#4'=56 <br /> PROPERTY Owner"�I O� U Addlress5 r1r— - y <br /> C-57 Contractor (,uowL.4 �rt� V Address t'O �0x 3�6 City Vlv. Zip9�I57ILic#7IdD74 Phone# 7o7-3-74-g3aa <br /> 11 1I11�� 3t N Gold Cn..,? Orae 96,- lw 2- 793 Phone#916-631- C3ZD <br /> Consultant l Sub Contractor_(��.L�f,�f-� - IKC_Address S� •�C 2d0 City Gordwya. Lic# <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED <br /> (JEW WELL I BORING(CPT,GEOP OBE,HYDROPUNCH,HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> a OVER-BORE <br /> 0 SO BORING# p PRESSURE GROUT <br /> %N LL# U- 1 <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLA ION TYPE CONSTRUCTION SPECIFICATIONS rr <br /> ;MONITORING HOLLOW SYEM DIA.OF BOREHOLE �S rrrr MULTIPLE CASINGS?BYES �[l0 WELL CASING DIA: 2 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 7t l� 1y TYPE OF CASING: a STEEL VC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1O b TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: tKyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOLTED TRAFFIC BOX or a STOVE PIPE <br /> p SOIL BORING 0 HAND AUGER APPRCONDOX.BORING UCTOR CASING PROPOSED?_-f YES,list specifications here): <br /> 0 OTHER:_G OTHER <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, and Rules <br /> State Laws, <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 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 California." <br /> T A P (CANT MUST CALL 4811 1 <br /> WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signedx� � \ o0.Vl(} 4- erLaq )_Title Gea(9 t54 DateVU <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: lQc 12 MCI <br /> p DEPARTMENT USE ONLY Area <br /> Application Accepted Byl —Date Issued 3- " 0 d <br /> Date Final Inspection By <br /> ,.yam.-t. Date -/GI- <br /> Grout Inspection By <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 I SE iCE REQUEST# INVOICE <br /> 350N 'Zi -\ BR "ckoS I- <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&W RS' COMP SATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI �— - <br />