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WELL PERMIT APPLICATION FORM <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 />ORMUL <br />UNIT IV <br />06 - W,11 <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 />WELL Location 0 Assessor's <br />�1Y1 t LJ0C)0, Cross Street - �ijj�v���I;ity _5 -Tor, I0 ;� �� Zip ci 5 % parcel# <br />PROPERTY Owner Address 13Q �G(&�In <br />"City S'1�CKI �� Zip�5L l Phone# 2QIr �1—Zip3� <br />Z_ fvx .j- s t . Rflsv�.l I <br />C-57 Contractor Dr,; ► I I P1(T_Address�ll ri 1 Z•` r�- 1 City co n , Zi Lis) I11Lic#SS�Phone# i% b 7z (P <br />Consultant / Sub Contractor f i E_ Address 7 rc'! S /j1 , w I bAncity5 %�.0 Iii •�,Lic# �2 7 Phone# <br />k c ,/ <br />GIS Coordinates X , Y Township 1 AJ Range Section L C` <br />WORK TO BE PERFORMED <br />'ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />"RUE LL #_ M Ul,",_ <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />'Other: <br />0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />;"ONITORING <br />>,(HOLLOW STEM <br />DIA. OF BOREHOLE �yy If MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA: <br />0 EXTRACTION <br />0\\AIR HAMMER/DRIVEN <br />CASING THICKNESS �~i%o�I�%� TYPE OF CASING: 0 STEELPVC 0 OTHER: <br />0 VAPOR <br />AIR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL Z fi TREMIE TYPE TO BE USED: 0 AUGERSOSE <br />0 SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />D OTHER: <br />0 HAND AUGER <br />OTHER <br />APPROX. BORING DEPTH ZS �j OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR 'YES, <br />_0 <br />CASING PROPOSED? AJ,, (iflist specifications here): <br />COMMENTS: C—L_ F <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS 1 <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." 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 California. " <br />HE APPLICANT MUST CALL 48 WORKING HRS IN ADPANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x ' ---` Till Date <br />e C - <br />SEE SITE MA IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY l/ Q(� <br />Application Accepted By Date Issued —/71OV Area <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />Date <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />2• <br />REC'D BY I DATE <br />(P_,4. <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />PERMIT /SER -RELjU INVOICE <br />23 vv <br />CLARATION <br />