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WELL. PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVE[ <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 16 1999 <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 />c�1 Assessor's <br />WELL Locations /��. ( / /i �(�-�/ J 1 Cross Street( City CnC�1 Zip�SzUZ Parcel# <br />PROPERTY Own/e�rL&e ��bo!)rK, Address 120 &C I ZtiC) City Jr�Cx1-.6— Zip SLI L Phone# <br />C-57 Contractor( CA.�CJ°PL_ Address ,3632 DyC- d7- City o 2CJ01—4yLic#712SJU Phone#r//&(3x!/61/ <br />Consultant / S <br />to Contractor 4r&,yG 2rU Address 171!2 klN s1- City Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />W WEL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />2 -WELL # Mw I) � wtw S, AMwl 0 PRESSURE GROUT <br />`Other: <br />PE CODES <br />COMMENTS: <br />AMOUNT REMITTED <br />CHECK # <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS �r <br />ONITORING <br />OLLOW STEM <br />DIA. OF BOREHOLE " MULTIPLE CASINGS? 0 YES O WELL CASING DIA: Z <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESSSCk 40 TYPE OF CASING: 0 STEEL B'ISVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL r, ' TREMIE TYPE TO BE USED: B-;�UGERS OHOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 32— - fflg'OLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />C <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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to G <br />WORKERS' COMPENSATION Laws of California." <br />JTf AP T MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />st L a/zoloa <br />Signed x Title CUlrS / Date <br />SEE SI E MAP N UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 1 1 /D 6 Area <br />Grout Inspection By Date 2 0o Final Inspection By �Cr1 Date Z <br />Destruction InspectionBy Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />�`��� <br />c6�.o� <br />OLo�I <br />!z I 4-10 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE WWORKERS'CONMENSAMON DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />