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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 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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 3yfu ti►6-loxT -tj gypb, Cross Street 9r Wf1,Js-0-AJ City ZipI 5Z4 5_Parcel#// <br /> PROPERTY Owner Moores k V1 Ad750750-6 �D S <br /> dress � �� � City STZip cls�honol�j <br /> C-57 Contractor ComV-- LJS'U-- Address-oZy I— CIIkLVO�N(4)y_City 55N Zip�S10�Lic#37/S&OPhone# /Z'Z -1�0 �J <br /> Consultant/Sub Contractor 46-7 E Address 060ST N-1.011 tlnl� City JTI✓M Licit Phone# 6G 7"405r— <br /> GIS Coordinates:X ,Y Township Range Section <br /> WOR <br /> K TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> 0 SOIL BORING OVER-BORE <br /> 0 WELL# RESSURE GROUT <br /> *Other: W ZVJ, <br /> COMMENTS: <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 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: f <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (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 /> .Q-OTHER:D*14tf,_0 OTHER ? CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: ST ��(c"?R4-�L � i V D1G� L' � T SLAC W p <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,State Laws,and Rules n <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 following: "l certify that in the performance of the work for which this permit is issued,I shall employ persons subject to y_ <br /> WORKERS'COMPENSATION Laws of Califomia ¢ __ <br /> THEAP.�L CAN�MUST CACI,4$.iN01?KINCa•�,.f,��t ' DVAN�F��[�;�l�;EQ�Jt�tE�E31N.,rP�''._,;_O�IS <br /> Signed x Title �� Date I�/CC d/� <br /> SEE SITE MAP IN NIT IV WORK PLAN DATED: oct- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r—� Date Issued l0 --/i —o Area n 7 s� <br /> Jf, <br /> Grout Inspection By Date Final Inspection By ,1 Date <br /> Destruction Inspection By c' Date l✓A/ f ,��, ti ,6� 2 <br /> C,� /�/� S, -/Lt <br /> COMMENTS CONDITIONS:C�OJNDITIONS: 5 a .•i ( / !' i6 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3s0of (a (oc� — /y 3 OL cz Lo/fflov G0 Ya Y3 <br /> G5'��ICEN D C NIRA( 'OR 14iiISTuSIG1�- C YST&�0�3£�RS'CO1tiiPE�SATIO�DE��ARAA�IE3�t <br /> UNIT IV-6/23/99/sign bkpg/MI _.- . . <br />