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-Q-BJ-G� NA L <br />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 instali 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 4 <br />WELL Location -r" rte,,Cross StreetQ� City 6 ' r ` 2ip���� ` Parcel#' 50' �0j2J <br />PROPERTY Owne�r� )L ► (ys K- Address o + 2� Cityt Zid�(�l'hone# q31 — gi 5 + <br />C-57 Contractor YW QrSTAy•►�+nAddress 1` j, city Zip '�"� r # ���%�� <br />consultant ub Contractorswddressi�rJ' %V W�r.�4l ity5�tc41 Phq ` 1�K� <br />GIS Coordinates X Y Township Range Section <br />WORK TO BE PERFORMED <br />)<NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />OIL BORING # 0 OVER -BORE <br />ELL # �_L � � _ 0 PRESSURE GROUT <br />'Other. �j�J <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />KiON1TORING <br />IKOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />PUSH POINT <br />0 SOIL BORING <br />Q HAND AUGER <br />0 OTHER:_0 OTHER <br />COMMENTS <br />CONSTRUCTION SPECIFICATIONS1 I <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA: L. <br />CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC a OTHER. <br />DEPTH OF GROUTSEAL t6 - TREMIE TYPE TO SE USED: 0 AUGERS 0HOSP <br />GROUT SEAL PUMPED- eyes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH OLTED 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 />hereby certify that 1 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 :he 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: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKER5' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL.REQUIRED INSPECTIONS. <br />Signed Title/Company <br />9 x hd�_ <br />Print Name `h/r✓�- jn-� Date <br />UNIT X11! WORK, PLAN DATE© 1 ' <br />D <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued �< �l S-oc� Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By 4K Date <br />COMMENTS I CONDITIONS 'T /'I 'Cco <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE [INFO <br />AMOUNT REMITTED <br />CjHECK # <br />REC'D BY <br />DATE PERMIT I SERVICE REQUEST # <br />INVOICE <br />sg#O�2 5 1 V <br />1/18/2000 <br />ZB 39bd NlDiADDiS 39d BTTTL9VISK TELT 00K/bT/TT <br />z <br />