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WELL PERMIT APPLICATION FORM UNIT !V <br /> i J <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 /> NOH-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 8-1 t 15 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> r 1 Assessor's <br /> WELL Location Po-cr�tc Cross Street �J�-k uy Parcel* <br /> 13'7^a ZO ^3 I <br /> PROPERTY Owner_U�°e.,-� �er•� _- Address 8788 R k Gam 01!4_ City E k Crts,_ zip 5 2 Phone#(q lG q-3205 <br /> C-57 Contractor Cas Ortlht;, Address 3432 Orcc- Ct"4e- city" ip jf 74Zl.ic#-717S10 Phone#tq[b 3$` 11b0 <br /> Consultant I Sub Contractor_ Siti-.g— CLC—_Address 3140 CJo C �r 170 CrryP .4,,Lrc* 5577 phone# fib 631 130b <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 4NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 13 DESTRUCTION(choose type below) <br /> a SOIL BORING# 13 OVER-BORE <br /> ($WELL# MU- 11 ti.r.., M w-i 6 [j PRESSURE GROUT <br /> *Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> N <br /> MONITORING 1,g34OLLOW STEM DIA OF BDREHOLE 8" MULTIPLE CASINGS?13 YES t&NO WELL CASING DIA <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS 5ck qo TYPE OF CASING p STEEL QVC 0 OTHER <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `IS'If '78' TREMIE TYPE TO BE USED Q AUGERS W`IOS <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED t•Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 31 <br /> a SOIL BORING p HAND AUGER APPROX BOIRfNG DEPTH 6a' Jf 90 `BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER _-_0 OTHER CONDUCTOR CASING PROPOSED? (it YES list specifications here) <br /> , <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 w0I be done in accordance with San Joaquin County Ordinances,State Laws and R <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 w <br /> for which this permit is issued,I shalt not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractor's hfang or sut <br /> contracting signature certifies the following 'I certify that in the performance of the work for which this permit is issued 1 shall employ persons subject to <br /> WORKERS COMPENSATION Laws of California <br /> T P ]CANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Titfe t� G�tn5 t f�_ Date Q <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED. <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByZ�o+ Lv r -& Date Issued Area <br /> Grout Inspection By Date Frnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FrArg <br /> PE COoESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WO ' COWENSATION DECLARATI <br />