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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 ISSUER <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> r� r 0726 41C41L Ave) �S�Z Assessor's Cray <br /> WELL Location t�,_,X e_ A[ . Cross Street 011-4- 5� City S zip Parcel# 53ree�' <br /> PROPERTY Owner C� err„ `7�ec�c Address 66 I-Ll k l _ ___ Cdy. SmkZip q 5 zot Phol,#' W'0 J17_,g5g9 <br /> C-57 Contractor C, City.R" ip557q2 Lic#_717576 Phone#616 658-1 l6q <br /> CS -994-1rc. <br /> Consultant/Sub Contractor 'Stc.,c C zAce Address31; o Y)r L76 CityRaIntig ic# S5 11 Phone#6410 651-I2' <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> OEW WELL!BORING( CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) Q DESTRUCTION(choose type belowi <br /> a SOiL BORING# p OVER-BORE <br /> WELL# M w- 1-7 it Mer-18^ _ Q PRESSURE GROU_ <br /> "other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA OF BOREHOLE —� MULTIPLE CASINGS?fl YES gNO WELL CASING DIA 2 <br /> EXTRACTION d AiR HAMMERIDRIVEN CASING THICKNESSL/O `TYPE OF CASING a STEEL WVC Q OTHER <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL �r47a TREMIE TYPE TO BE USED Q AUGERS VO: <br /> Q AIR SPARGE a PUSH POiNT GROUT SEAL PUMPED *Yes (I No (NOTE: MAXIMUM FREE-FALL DEPTH fS 3 <br /> SOIL BORING u HAND AUGER APPROX BORING DEPTH 66' d 90 r_ AWBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> OTHER 0 OTHER CONOUCTOR CASING PROPOSED (if YES list specifications here) <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws and fi <br /> and Regulations of the San Joaquin County Homeowner or licensed agents signature certifies the following 'Y certify that rn the performance of the r <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws ofCattforma" Contractor's hiring or su <br /> contracting signature certifies the following 1 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 /> TM AP LIC T MUST CALL.48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> II i d <br /> Signed x Title,�l� CC.P�.�ia S� Date <br /> SEE SITE MAP 1N UNIT 1V WORK PLAN DATE. _ 3 [ U o . <br /> DEPARTMENT U51_ONLY <br /> Application Accepted By E}[ date Issued f s �_� i Area <br /> Grout Inspection By Date Final Inspection By. _Date <br /> Destruction Inspection By bate <br /> COMMENTS I CONDITIONS <br /> ffACCOUNTINIG ONLY AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITf SERVICE REQUEST# INVOIC <br /> 106151705 .�/1 &a <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &1WORKERS' COMPENSATION DF-CLARAT <br />