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9-22-1999 A:OBPM FROM r•a <br />M <br />WELL PERMIT APPLICATION FORM <br />IBY ---- <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' L <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 W <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 ;n compliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ ental ealth Division. <br />WELL Location � q E <br />FY,41^ )At 5 -r. Cross Street l I Deer ST City STn ck�M rP 4 Sao 5 Parcel# <br />PROPERLY Owner LI }t 6 F STOL�IA/� Addresszw-N' LVA��ad° yT city zip <br />Srocktwl %f�0� Phone#o?�9-`131�83�i <br />GYr�a Ste S)t� Address zip y Lic# 6f�YO7Phone# �dS-3l3 S_8ao <br />C-57 Contractor_y5� � WC!. City r7III L �i� <br />(�,� hrrG �n 0 Address r 7 nl 5 f City L�1A1�iq LiG# T��l� pttpnetf 7o7-93sys�a <br />Consultant! Sub Contractor— <br />Y <br />Township Range Section <br />GIS Coordinates: X � <br />WORK TO BE PERFORMED <br />Q DESTRUCTION (choose type below) <br />NEW WELL /BORING CPT, EOPROBE. HYDROPUNCH. HAND AUGER, OTHER? a OVER -BORE <br />SOIL BORING # 0 PRESSURE GROUT <br />Q WELL # I <br />'Other: <br />C,-MMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIF TIUN5 � YES VNO WELL CASING DIA: <br />0 MONITORING Q HOLLOW STEM DIA. OF BOREHOLE A" MULTIPLE CASINGS Q PVC Q OTHER: <br />0 EXTRACTION Q AIR HAMMER/DRIVEN CASING [hi A /TY�P/� OF CASING: [] STEEL Q <br />0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL i� T1MlE TYPE TO 8E USED: n AUGERS :HOSE <br />0 AIR SPARGE PUSH POINT GROUT SEAL )� Ytrs 0 No (NOTE: MAXIMUM FREE -FALL DEP ) <br />SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH yS Q BOLTED TRAFFIC BOX or 0 STOVPIPE -n4)E <br />0 CONDUCTOR CASING PROPOSED? /u ( if YES, list specifications here): <br />OTHER: (1 <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />nd Rules <br />nances. State Laws a <br />1 nereby certify that I have prepared this application and that ticensedhew-rk wall be done in ure Certifies thetfo owing:"I certify th2tt inui County �the performa ce of the work <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signet <br />for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor'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 steell employ persons subject t0 <br />WORKMAN'S COMPENSATION Laws of California.' <br />E AP ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Titl <br />r to <br />Signed x <br />SEE SITE MAP I UNIT IV WORK PLAN DATED O <br />DEPARTMENT USE ONLY ea <br />Date Issued <br />Application Accepted By Date <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date jf) �27 <br />7 <br />COMMENTS / CONDITIONS: <br />