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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 DD <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 County Public Health Services, EnvironmentalHealth Divis.on <br /> Assessor's <br /> WELL Location %bZ% ZCZ61L.s%a.- ¢a ss Cross Street Q+�•w..<\ c. City S�<-�-��^ ZipQS�71 Parcel-, ((If-eO "'o4--C� <br /> PROPERTY OwnerC�^-4.�0 Sc�wis� AA tress tRIZ <J��� Q\�Ac,� 05. CityS 1L-`t` Zip�s�� Phone b9Q <br /> M VNO \' <br /> LSA-�to4e�1 <br /> C-57 Contractor l� UVJ ck.,•knn 11K- ` lAddress Q'�' ��X 41 L City, I5ke.��nll�''�__ _Lic-, Phone-, 1 17,)-y100 <br /> W_ Address%%Ct141 pokes\ 14C City NA" <br /> __ -' <br /> Li,--Phone," at <br /> Consultant/Sub Contractor ATL. ttsSCL\o� <br /> GIS Coordinates:X <br /> Y Township Z Range F_ Section 33 \ <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type be!o.v; <br /> 0 SOIL BORING-, 0 OVER-BORE \ <br /> 0 PRESSURE GROUT <br /> WELL-, PA-0 Z <br /> 'Other: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF;C?TIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? YESNO WELL CASING DIA <br /> Ak�PR: <br /> CASING THICKNESS sc..."0 TYPE OF CASING: 0 STEEL VC 0 OTHE <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN ^ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 31 TREMIE TYPE TO BE USED: 0 AUGERS 7HOSE�3 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'� <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Z1, BOLTED TRAFFIC BOX or 0 STOVE PIPE t <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?t_(if YES, list specifications here): \ <br /> V <br /> COMMENTS: <br /> I <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 Rui <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 wo <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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company <br /> Date <br /> Print Name <br /> SEE SITE MAP IN UNIT IV WORK.,-PLAN DATED: - <br /> ` 1 DEPARTMENT USE ONLY <br /> 9 �, �! Date Issued 01 ` � �` Area__._— <br /> Application Accepted By <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By ate <br /> COMMENTS I CONDITIONS: _f r �� <br /> ACCOUNTING ONLY: AID-, FAC:"= <br /> PE CODES FEE INFO AMOUNT REMIIT-ED CHECK» I R C' B I DATE PERMIT I SERVICE REQUEST-, INVOICE <br /> 1/18/2000 <br />