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o . ORONAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 6)r' <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 />L !_ �^i3-7t Parcel# C,:!!4 oa Ic�e�i <br />WELL Location J �' 1�(�'htLr I `T' �I Ce.1�i _Cross Street I ��` 4:c6,t11�1 City 1 i roc Zip , T <br />PROPERTY Owner CIL 2E 1 l ac y Address ���i sT- 1 � � � ��Ci� � City � RSC Zip X15 3 �� Phone# � �Lr(� �� ! <br />�' 71 7iii Phone# 116-- X38._ <br />C-57 Contractor Cl cc� �� Address Circ1� City Cn.7e+C� Zip4�7-IZLic# <br />p t -A \1Q 7 116— 61i - 136V <br />Consultant /Sub Contractor Cye - R—,x 1o... Address�ZVE• City �� Lic# 5S 1 Phone# <br />GIS Coordinates: X I Y. <br />WORK TO BE PERFORMED <br />Township <br />')(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER <br />0 SOIL BORING <br />- _ � <br />'Other: <br />COMMENTS: <br />t]►J <br />Range Section <br />OTHER') O DESTRUCTION (choose type below)` <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />re l•A TI kl <br />2MONITORING RIiOLLOW STEM DIA. OF BOREHOLE ''. MULTIPLE CASINGS? 0 YES �j'NO WELL CASING - <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �.. �� 4`-' TYPE OF CASING: 0 STEEL �RPVC 0 OTHER: <br />TREMIE TYPE TO BE USED: O AUGERS OHOSE <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br />PUMPED: 0 Yes JJ(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 AIR SPARGEO PUSH POINT GROUT SEAL <br />I BOLTED TRAFFIC BOX or O STOVE PIPE <br />O SOIL BORING O HAND AUGER APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />0 OTHER:_0 OTHER <br />COMMENTS: <br />BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />NOTE: OFFSITE <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 />the following: "I certify that in the performance of the work <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies <br />is issued, 1 shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />1 <br />e <br />for which this permit <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 />WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPEyCTIONS. <br />T APPLICANT MUST CALL 48 <br />� (�l` <<'c-� )c :� ,:�i ;'�" Date 10% I'I 110 b <br />Title <br />Signed x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Date Issued ! l 0��mea <br />Application Accepted By }�' <br />to <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />05Z Z -- •a �-," <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SER ST # INVOICE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C ECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />