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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE�RVICEi' i <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 93202 P <br /> (249) 468-3449 FILE COPY <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/Q1 install the work descrioed. This apiodcation is made in compliance with <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Puolic Heafth Servioes, Environmental Health Division. <br /> WELL Location �j, kKW` AssessJr's <br /> �L w - t��''�C Cross Street r��/1r7,�nt�'�y12 City �.�/� ZJp Parcet# <br /> PROPERTY OwnerV0101`` NAVVI VX,Q Address � ii- CG,A City 111rY'l/T Zi�Phene#__ �2� <br /> C-67Contract WAQN Ci? �Address V'IIXJ l7• %U/,1�1•t �• City Kn�1 /,' L�7 <br /> Conwltartt/Sul)Contractor.l�i(}Gi'(�(,(41�1(XoI P�Address�� l i1'h V� CityMt.Vl�'Jf� Lic# Phone#6156-god• 1lDM, <br /> GIS Coordinates:X Y Township Range_` Seddon <br /> WORK TO BE PERFORMED <br /> W"WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# ID fl OVER-BORE <br /> rl WELL# / R-ITRESSURE GROUT <br /> *Other:156L, 5 <br /> COMMENTS: Qts f I�U—) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS,0 YES -VNC WELL CASING DLA <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS +r _TYPE OF CASING 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: fl AUGERS DHOSE <br /> 0 AIR SPARGE FfUSH POINT GROUT SEAL PUMPED: fl YeesN <br /> r o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> '1 <br /> fl SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH Mk4 0 BOLTED TRAFFIC BOX or fl STOVE PIPE <br /> fl OTHER: Il OTHER CONDUCTOR CASING PROPOSED? PD (rf 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 wig be done In accordance with San Joaquin County Ord nances,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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the fogowinq:`I certify thal in the performance or the work for which UNs permit is issued, I shall employ persons su)�&d to <br /> WORKERS'COMPENSATION Laws of California.' <br /> PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Sign x . TitleJ 61f&ee N 1V QJk61E$Z— Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 7- !s <br /> Application Accepted By. Date Issued J Area 0� <br /> Grout Inspection By Date Final Inspection By Date <br /> A" <br /> Destruction Inspection By Date <br /> COUMENTS/COND1T1ONS: RC1 9 0 upOK ClJQhJde.6 <br /> ACCOUNTING ONLY: AID# <br /> FAC-4 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED BY DATE PERMITISERVICE REGI NUMBER INVOICE <br /> UNIT IV-6/23/99/sign bkpg/MI <br />