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WELL PERMIT APPLICATION DORM 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 <br /> San 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 /> WELLLocation2.6(2 W.A/.-A�g4/ct Cross Stree O City Zip95z05 Parcel# I11'O*0-3 <br /> PROPERTY Owner:y�",� �etYr��lo Adddress j-2&4 a City s oe,IC Zip9,C20JPhone#$DO Q586- <br /> C-57 Contractor, �`�� Address RSO Pout &I Cityrj[liu�-r,Zipr?[ES33 Lic",4S/65Phone#�Z5 3/3-58'00 <br /> Consultant/Sub Contractore&y ud Zero Address I7/4/A0*4/ Sf' City t (A- Lic# Phone,83�'SBfSr' <br /> GIS Coordinates:X ,Y Township Range ( Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORIN CPT EOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# AP 7' / GP 144 0 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 Z MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR VM ROTARY DEPTH OF GROUT SEAL //D TREMIE TYPE TO BE USED: 0AUGERS0 AI PARGE H POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH /l0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if 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: "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'COMPENS s of Califomia." <br /> TH PLICA MUST CALL 48 KING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title /�7T��Date !/1/7l0-1) <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> D PARTMENT USE ONLY l (� �f <br /> Application Accepted By Date Issued No �% 2 L � Area <br /> Grout Inspection By Date_yj Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D RY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 s�� ea® D it ZZ Z 2 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LIAN & RKERS' COMP_ENSA ON DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />