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WELL PERMIT AP •PLICATION 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 San <br />Joaquin County Development Titl Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />57„yt� Assessor's <br />WELL Location Y�Ci Cross Street Ci Zip �� �cParcel# <br />PROPERTY Owne Address ity Zip/9 5Z - )EQ hone# <br />C-57 Contractor v4es�-,�i /�lW(Addres City_Zip��L 47 ` Phone Z/ r” <br />Consultant/ Sub Contracto^ 677 Address QZIv ry1 .1� � Ci 7 Phone# ' Z? <br />PE CODES <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />WOR <br />L3!F�?—L <br />K TO BE PERFORMED <br />ff <br />r �Z2�fI <br />c0/�/�SR# <br />W WELL / BORING <br />( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 OVER -BORE <br />0 WELL # <br />0 PRESSURE GROUT <br />`Other: <br />COMMENTS: <br />I <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MONITORINGt4OLLOW <br />STEM <br />DIA. OF BOREHOLE �� MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: rl <br />O XTRACTION <br />�}tIR HAMMER/DRIVEN <br />CASING THICKNESS -n" -Z— TYPE OF CASING: O STEEL_,.ffPVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEALZ1SF&ZXfi TREMIE TYPE TO BE USED: ,$-A'IJGERS OHOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes jrllo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH—:�VrllnO� .FIB_OLTED TRAFFIC BOX or 0 STOVE PIPE <br />L <br />/\ <br />O OTHER:_0 <br />OTHER <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS <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 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,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of Califomia." 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 />WORKERS' COMPENSATION Laws of California " <br />THE AP PIL CANT` T CALL; 48 WORKING I IRS PINS. <br />Signed x Title V� �V� Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: ZaT� <br />DEPARTMENT USE ONLY <br />Application Accepted BDate Issued Area D 7 S <br />Grout Inspection By —C �u-(' G _Date li ,&V Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />L3!F�?—L <br />?'q <br />ff <br />r �Z2�fI <br />c0/�/�SR# <br />00-7 V/1 -7— <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARAATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />