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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 <br />San Joaquin County D(�evv�elorppment Title,, Chapter 9-11115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location �ytJ `/ �- ��`� �-- , rye �O 7 Assessor's <br />Cross Street 1'?Vr�`�C�— City 1t'f' Zip%%Parcel# <br />PROPERTY Owner +>((�, / Jc.w-k��%s Adddress-�� 67�' `�"� J53 <br />City 7Zip 7�, hone# c, <br />C-57 ContractoF /f - G65) Address 3 rr�/I'T 1'( - City C X14 Zip f ic# '�! r E hone#1�% <br />onsultant Sub Contractor / `= Address !�)� �UZ\��G_CityJ/tdJ-4,!)c# Phehe#r <br />GIS Coordinates: <br />WURK I U BE PERFORMED <br />Township <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # VAwl Mwz I w�w3 <br />0 WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />OONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS <br />INSTALLA <br />R -'HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />-0 OTHER <br />CONSTRUCI <br />DIA. OF BOR <br />Range Section <br />,,B'bESTRUCTION (choose type below) <br />0 OVER -BORE <br />-0-PRESSURE GROUT <br />IONS <br />MULTIPLE CASINGS? 0 YES O WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL VVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE U ED:AUGERS ,01!IOSE <br />GROUT SEAL PUMPED: 0 Yes,L 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH � ,fffOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 1� <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 California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x J I Title i, T' Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: A44-r,,1,-eA 1-2AP-00 <br />DEPARTMENT USE ONLY <br />Application Accepted By /0-. a -e a- Date Issued /- 3/-O0 Area D 7S(o <br />Grout Inspection By 1117Dat F <br />Destruction Inspection <br />COMMENTS/ CONDITIONS: t n wt�ac6.. <br />e final Inspection By <br />Date- <br />- 1 Al r,• <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ST # <br />INVOICE <br />3TO2- <br />Coote <br />d— <br />I'-) <br />(9L 4S <br />C-5/ LICENSED CON RACTO MUST SIGN LICENSE &WORKERS' DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />