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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 County Public Health Services, Environmental Health Division. <br />A ` Assessor's <br />WELL Location <br />`i ', 7 w r h� Cross Street �� 1 +i'3r K t City x {t �c ; Zip �6 ?6 Z Parcel# 1 3`1 Z `�, 7 <br />�!''740t_ Cit Zip �L'�� I Phone# rl 16 71� <br />PROPERTY Owner �.�nx—,I � rO r'c.-�� •^ _Address Yy � y <br />- � - ! l6 `! <br />i 1 7y2 7i7 �kPhone#�)l� G�� <br />C-57 Contractor «s�c�I�G L:'�, �'. Address 3�3 G IreC CC �Q City? aiP �� Lic# <br />Ski - (F�-li Phone#k('6-631 13(b <br />Consultant/ Sub Contractor Com— r..� �r� Address �`� �� (? Ir; `� City �nrOC� LiC# J <br />Township Range Section "v <br />GIS Coordinates: X . Y \t <br />WORK TO BE PERFORMED <br />DESTRUCTION (choose type below) <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 OVER -BORE <br />SOIL BORING # PRESSURE GROUT <br />ea WELL #;t-2`�y,� a, .' - � �i �51� - ( iir•-.. �� �, ^i . i.� <br />'Other: <br />COMMENTS: � <br />TYPE E WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING Q HOLLOW STEM DIA. OF BOREHOLE �* J Ir "� MULTIPLE CASINGS?�YES1 RNO WELL CASING DIA:3 � �I <br />EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Sc In qV TYPE OF CASING: 0 STEEL _1,PVC 0 OTHER: <br />'<VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S -e I- c l .• TREMIE TYPE TO BE USED: a AUGERS �}10SE <br />XAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: QYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') n <br />�, OLTED TRAFFIC BOX or 0 STOVE PIPE <br />a SOIL BORING o HAND AUGER APPROX. BORING DEPTH ��e �:r x 9� <br />0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: 2 m I 7' fl i 2C ,. `I ` � 7C' c `c' ) p <br />. 1, �., R�EQ <br />NOTE: OFFSITE BO INGS IRE 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, 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, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California.' <br />T LICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title <br />t R`\eG� G�iog11S Date IG ri 41 <br />Signed x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Date Issued I �% I' �% G AreaJ`j 0 3 <br />Application Accepted By o �v "^ <br />Grout Inspection By <br />Date � � � v 0 Final Inspection By --`� Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RAE'tD BY DATE PER <br />UEST # INVOICE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COi� ATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />