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1707 935 G649 P.01./02 <br />WELL PERMIT APPLICATION FORM <br />UNIT 1V <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />Appiicatfon is hereby made to San Joaquin County for a permit to construct andlor 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_ 2 `!9 `IFvew,nn� Styst+ Cross Street Assessors <br />City+oc.k.+on zip Parcels <br />PROPERTY Owner n .; /sn �Addross 'w: k Iasp as ity <br />Z1p 7yp0.4i Phonels <br />C -S7 Contractor >•" Address Q Se "O V" Rs a J City 1(�1LLeL ZI <br />p9T.S&; LicuMV 3Sl(Sl(.S Phones f2S 3 13 S fbe <br />Consultant I Sub Contrector_clum �, h; Address D `a <br />City Soti �L;cAt Phone* 70l 437 �t5� \ <br />GIS Coordinates. X Y Township Range <br />Section /b <br />WORK TO BE PERFORMED <br />It NEW WELL l BORING (CPT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER-) U DESTRUCTION (Choose type below) <br />JKSOIL BORING s _.SR -4 p OVERBORE <br />aWELL s� -y <br />*Other 0 PRESSURE GROUT <br />*Other Fiu}•ti.4S t.1:It b .�an i PT Maw's <br />COMMENTS. 3)P F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ItWONITORING $HOLLOW STEM DIA. OF BOREHOLE ~ MULTIPLE CASINGS 0 YES V'NQ WELL CASING DIA .2 ~ <br />0 EXTRACTION 0 AIR HAMMEWORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL JfPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY 09PTH OF GROUT SEAL A- y3 f� TREMIE TYPE TO BE USED, 0 AUGERS ,§10SE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED- XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX BORING DEPTH •ffl I(BOLTED TRAFFIC BOX or Q STOVE PIPE <br />Q OTHER: 13 OTHER CONDUCTOR CASING PROPOSE07_,yg__ (if YEs, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />hereby certify that I have prepared this application and that the work will be done In accordance vnth San Joaquin County Ordinances, State Laws, and Rules <br />and Regulation& of the San Joaquin County. Homeowner Or licensed agent's signature certifies the following: '7 ca"Ify that in the pertbrmance Of the work <br />for which this permit Is issued,/ shall not employ persons subject to WORKERS' COMPENSATION Laws OFCallfonrla." Contr2ctor's hiring or sub- <br />contracting signature certifies the following: -I certifY that in the performance of the work for which this Permit is issued. I shall employ parsons subject !o <br />WORKERS' COMPENSA77ON Laws of califomra.I <br />E APP C MUSTCALL 48 WORKING HRS IN ADVANCE FPR ALL REQUIRED INSPECTIONS. <br />Slpned — Title iEaf E.oi.,et•r Date_I I s 199 •_ <br />SEE SITE MA IN UNIT IV WORK PLAN DATED: l0 -fl-5 <br />DEPARTMENT USE ONLY // <br />Appileation Accepted By Date Issued ` I — 2— <br />Grout <br />Grout Inspection By 101, <br />Date Final Inspection By onto <br />Destruction Inspection By 41 Date _i--virMI <br />COMMENTS t <br />ACCOUNTING ONLY: I AID* <br />PC CODES I FEE INFO I AMOUNT REMIrrEo I CHECK a <br />C-57 LICENSED C0N7'RACT0A MU$T11s1(? t <br />UNZT IV - 6/23/99 /sign bkpg/Mt <br />REC'p BY DATE PERMIT I SERVICE REQUEST r INVOICE <br />�� ps <br />1�SE;&W"CQMPENSA'ION DECLARATIQN <br />