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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 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 Coun. PublicHealth Services, Environmental Health Division. ' <br />{� c� t'k% Zi ��'S ZL% Parcet# Assessor's <br />WELL Location (-I / ` i Cross Street �Y�� 1 City p <br />PROPERTY Owner Lt A yin-rf-o'\ Address Cnity Zip Phone# <br />_P1� i)�L"'i µZi �` cl Lic CrL��` Phone#Jl0 23L 'N <br />C-57 Contractor (-`I I -t K Address Ze 5 � (t•-� CJM � City P <br />Cultant/Sub Contractor C&6LI AddressSIL` 4 art:+ _City Lic# Phone#S/Q %-Y3 <br />GIS Coordinates: X . Y . Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING (CPT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER-) Q OESTRUCTION (choose type below) <br />;> SOIL BORING x / Q OVER -BORE <br />Q WELL # Q PRESSURE GROUT <br />"Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />p MONITORING <br />Q HOLLOW STEM <br />Q EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />0 VAPOR <br />Q MUD ROTARY <br />Q AIR SPARGE PUSH POINT <br />A SOIL BORING Q HAND AUGER <br />Q OTHER:_0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z�I —MULTIPLE CASINGS? 0 YES ENO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: U STEEL Q PVC Q OTHER: <br />DEPTH Cl: GROUT SEAL TREMA= TYPE TO BE USED' D AUGERS UHOSE <br />GROUT SEAL PUMPED: Q Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'. <br />APPROX. BORING DEPTH -5( Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS_ IenT rc. V il%� -I�ti CGi t �tv� �.1d 6,J xrMnl, S <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 Rule <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, 1 shall not employ persons subject to WORKERS' COMPENSATION taws of Califomla_" 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 shall employ persons subject to <br />NJORKERS' COMPENSATION Laws of Califomie. - <br />CALL THEUNIT N SPECTOR 48 WORKING HRS IN ADvAN.CE.FOR-ALL REQUIRED INSPECTIONS. <br />Signed x C '' TdlelCompany 1 r cA <br />Print Name C�" I I r,rl An. .� r Date <br />SEE`StfE=I41A DARTED- 5..~ <br />`Pi:>IN'-�U1�#; �.k� �1'DRKsP1:A1� .-.:.��:�ti:•�.,.,.,,41 :� �:,� <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued -2— o Area <br />inspection B <br />p <br />Grout fns _ �a ti: A a:j= _Date O Final Inspection B Date <br />— <br />Y <br />--�L� — - <br />Destruction inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />RECD BY I DATE I PERMIT / SERVICE REQUEST # , INVOICE <br />