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ORIGINAL <br />nn41� WELL PERMIT APPLICATION FORM UNIT IV <br />� �V4 <br />® SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �b <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) D v- <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 Joa uin Co my Develooment Title Chaot r 9-1115.3 and the Standards of San Joaquin Count ubl' H alth Services, Environmental Health Division. <br />��_AA '� I/a /fAssessor's <br />WELL Location C-i�NT t;' &liT- OF -W,-K * Cross Street C Zip Parcel# go �41 <br />PROPERTY Owner SAN a2AQQ-r4 Ls2s2 ITY Address S10 HA7-ELy"4_ AYE. City GT-0cY-10-)Zip SZ 5 Phone# CZo'04C-,fs-34W-;\ <br />2P,tvcNc <br />C-57 Contractor CA5c8K2E D1:LLLZNCt Address 36 i% OMEC CLFLC.LE Cityco2ncrP. Zips- -t 2Lic#7t75io Phone#i -i l6`1 <br />;apv'ANCED G Ei:- <br />Consultant / Sub Contractor SntvLR-CINMelVTA _,ZrvC Address `3',1 S NAW ►.0. City Lic# Phone# (zc�i)yc.�-tcr <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED <br />NEW WELL/ BORI PT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING # <br />SWELL # Mw .- 11 - 20 41i 22, ? 3, 244 <br />'Other: <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />COMMENTS RCFEp>EN(E /ai Ac t1h L1 ��vt� P L -INN V1/�T =D 15 SIGNy�tZY 2C:C� . <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE ! MULTIPLE CASINGS? J&YES ONO WELL CASING DIA: 2 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS tcwFg,_Ey0TYPE OF CASING: 0 STEEL )KPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1- Co_5'f�SCr TREMIE TYPE TO BE USED: R'AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: g Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH St,'Amt) RG � a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED?_r4 12� 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." Contractors hiring or sub- <br />contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />IF <br />z <br />O <br />Signed x -JZ� ez 1A" Title/Company SyAFF S ,-EntTZ-iT/AiN,18tdc ED GEo�NytEs�NM1�N�At- <br />Print Name P, EGL -Y LE Date 2/ 1 3 i o7 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY O/ �T <br />Application Accepted By Date Issued Area v T <br />Grout Inspection By Date t Final Inspection Date 'd7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FA <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE PERMIT / S <br />INVOICE <br />So <br />3+4. 2,57-39 <br />CKA <br />SSI 0(v <br />1/18/2000 <br />