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WELLPERMIT APPLICATION FIRM 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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public He Ith Services, Environmental Health Division. <br />s� / r'�r�Iw� � - (, �" Assessor's <br />WELL Location /f Cross Street � j� G7�' City Zip ✓� Parcel# p <br />PROPERTY Owner VI, S��z;�- Address `f LJ l" CL City 57 G Zip �Phone# 147 0(o&� <br />C-57 Contractor <br />Consultant / Sub <br />GIS Coordinates: X , Y. <br />ress7a N � GU1rS�1 <br />Township <br />K TO BE PERFORMED <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />t 0 SOIL BORING # <br />0 WELL # <br />'Other: <br />COMMENTS <br />�TYU OF WELL <br />INSTALLATION TYPE <br />ib�ONITORING <br />*OLLOW STEM <br />0 EXTRACTION <br />D AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />O PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMME <br />Range Section <br />O DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS f� <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? 0 YES10 WELL CASING DIA: <br />CASING THICKNESS D ®2 TYPE OF CASING: O STEEL ,B'1VC O OTHER: <br />DEPTH OF GROUT SEAL/15r1a;r-T­TREMIE TYPE TO BE USED: 'Er�6GERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 30 .BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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: `7 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, l shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />Signed <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: �&� �2 x/n, <br />DEPARTMENT USE ONLY �s-77 ter' o'`f <br />Application Accepted By Date Issued ZO-3 —av Area 6-1 7 S-% <br />Grout Inspection By Date// -(c uv Final Inspection By Date <br />Destruction I <br />COMMENTS/CON <br />Date <br />cc<-fJ <br />Jt \ <br />ACCOUNTING ONLY: AID# <br />CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHE(�CK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />IPE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARA"I10N <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />