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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 />(209j' 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/Qr 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 />WELL Location 3 5aa We►{n RoAd Cross Street W . 33 City E14NAL1S Zip 963&S Parcel#�5$- -0-03 <br />PROPERTY <br />PROPERTYOwnerpr+,-ld Doneen Qellji. Address4C410 le/.D-.-h4M Feet-yR y -Tr -,'-4 Zip Phone# cia <br />C-57 Contractor Clr'e�� Dr • 1 ��� 4 CO. Address ,50 O W 6 1�0. Cityl")4;,%c,%. Zip`I `1533 Lic# -f 85i6SPhone# 5ta 313- -Two <br />onsulta t / Sub ContractorcleorIa-v�i x 1.nonsAV&AA-Address alol We -10S4---- 5+. CityQQ l<)­�' Lic# Phone# 510'663.43,41 <br />.1 a+" F1ovQ - <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />XNEW WEL / BORING CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) S g _ 13 <br />�� <br />11 SOIL BORING # S8-� ,s 4 -!O, S[3- li SQ- 1a <br />0 WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTI <br />Q MONITORINGHOLLOW STEM DIA. OF <br />ONS <br />MULTIPLE CASINGS? 0 YES 160 WELL CASING DIA: 41A <br />0 EXTRACTION I] AIR HAMMER/DRIVEN CASING THICKNESS oJA TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-;,) it DA K ill TREMIE TYPE TO BE USED: (AUGERS -ir• �(-tOS <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS.30$ <br />`SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 10 ' — 70 r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_9 OTHER CONDUCTOR CASING PROPOSED? Ah (if YES, list specifications here): <br />COMMENTS: 0-;11 bo. :23s 6 IPA d.�.nUlre�tJ 1 I�ow-lr2v�► e„. 0ne- bei, , 40 0 <br />3O r1 O One+ - i n O Q o11� SOS a-, r« �n ('bJr•�...s o -t Com' S ILS <br />NOTE: OFFSITE BORINGS REQUIRt ACCESS OR ENCROACHMENT PERMITS <br />DESTRUCTION (choose type below) <br />0 OVER -BORE C%1 <br />KRESSURE GROUt- <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 />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, I shall not employ persons subject to WORKERS' 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,/ shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />TH PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title �i�%�% Q�� twrw F,41roate <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By��1� Date Issued S�/ /D Z Area d$ L✓rL✓G <br />Grout Inspection By Date S Z z O2 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />FAC# <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE IT/SERVI ST NUMBER INVOICE <br />UI -dl <br />/0 TY3 <br />f"r/a <br />C-5-7­t <br />C�?NTA,CTC7R'1VtS'I'..:X,LTCENSE&W'C7RK)�Z:. IVT�F1'VCS..F AATYQ1 <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />