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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> t}y� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �/� <br /> a ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) I V <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <br /> (209) 468-3449 <br /> 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereor 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 Count Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> / <br /> Assessor's <br /> WELL Location !s �� a01A � /�," � s�.. Cross Street Z! �yi-r- City Zip 953UQ Parcel# <br /> PROPERTY OwneerlJ�^^�s a 'r_ rte'----Address ,15;97,0 _At. <br /> , ib� ZiP Phone# ��$-¢3`aS <br /> C-57 contractor I-t���Ml+rAettOr^r�/dress 5-AcOA W� City SIfG• Zip9S 6 Lic#67Z�a1 Phone# )-4-Io60 <br /> Adw"tez <br /> il(onsur" /Sub Contractor ,X,Q- rr a��' '�- Address 4605'N•Wilcw.J W1. City "Cki Lic# Phone# 4foT-/6cyrp <br /> i� GIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> &419W-WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> Q SOIL BORIN t�� 0 OVER-BORE <br /> &fIELL# Z ( /l�Gfif/ 0 PRESSURE GROUT <br /> 'Other: <br /> i <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSaAT- "� <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE B-LdkAMULTIPLE CASINGS?Q YES �,rvv' WELL CASING DIA: 2-ktil <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Ol TYPE OF CASING: 0 STEEL A$kJC` 0 OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL O rbmfTREMIE TYPE TO BE USED: . JGERS OHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes ja-R (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 8 Va6LTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: Q OTHER CONDUCTOR CASING PROPOSED? AI (if YES, list specifications here): <br /> IIICOMMENTS: <br /> NOTE:!. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that Ihave 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: "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: "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 Califomia." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> fSigned z�?7 v9ei�"'�' '" Title/Company 9Y- QWb 1 15 fAtU ,,-,d'^eDrJ�i?Rsv1We`d '+c' <br /> Print Name .—/Bi✓1/t! �t G- I Date ©7/24-/00!, `BMW TAJyA)I4Tl0!�wF1 r <br /> EE SIT MAP IN'UNIT IV WORK nPLA DA EDLL 2� Sin J� ,Z80_= <br /> K DEPARTMENT USE ONLY P-11-D6 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Dale Final Inspection By ate <br /> Destruction Inspection By` Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# / <br /> PE CODP <br /> FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT/SERVICE REQUEST# INVOICE398 f 4 ✓ 1/18/2006/7 <br />