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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) 488-3449 <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 /> t n 1 Assessor's <br /> WELL Location M4 dIie- L112W1S LrlUC crosss[tr/eet 1x City TBY1 zip,�Dl Parcew <br /> PROPERTY Owner <br /> r^, e�yee,) 6lC1SS /Address 1 7 I If t'P City Zlp^�,.��JPhone# <br /> C-57Contractor i�A.�v Jfe0EA/V,/ 'J Address q�S ✓y.�.J{'. City ZipSS2�Lic#�hone# U67'/006 <br /> Consultant/Sub Contractor A&G _ Address l t,'k On Lia>&a27 Phone* y -IUYo <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WOR <br /> ��-K TOO BE PERFORMED <br /> �q,NtW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> _\ OIL BORING# 61- O5` D OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2L ULTIPLE CASINGS?0 YES 0 NO WELL CASIN <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL r—n+ire TREMIE TYPE TO BE USED: 0 AUGERS )-41%T0SE <br /> p AIR SPARGE )PUSH POINT GROUT SEAL PUMPED: 0 Yes INo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> *OIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: R OTHER CONDUCTOR CASING PROPOSED? /T V� rff 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 will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <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 Ca#Pomia." Contractors 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 Callfomia." <br /> Signedx Title Ceolc�-i/ 5� Dale. lio <br /> r uh. /Nr n'Rn <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: O, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dale Issued /0//0/00 Area /7 <br /> Grout Inspection By Dale Final Inspection By Date <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/SERVICE REQUEST# INVOICE <br /> glcu SR# Cc>a 30 <br /> UNIT IV-6/23/99/sign bkpg/MI <br />