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0--110J1 jA, e...Q.- <br />04Sj4v- W& <br />WELL PERMIT APPLICATION FORM <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 />UNIT IV <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 />Assessor's <br />Cross <br />Cross Street City S E�� F =� Zip 1 s 262 Parcel# 6 -6 S� k 1 <br />WELL Location <br />1 `` ij _ , <br />C �c � a['?C-G-k,,l Address yZS N. el IX d.J S� city -Zip Zip(ISZ?Z Phone#'2'ul-`t3 7-�3 7 <br />PROPERTY Owner � y � <br />i f HCl^ -n <br />C-57 Contractor �� `<: <- I �1r�. Address ;C=�� {�nr.tr �� CityZlPcl��`�ZLic# fr?S`t Iv Phone# tb E�S,- 116�i <br />c�_Mk : <br />Consultant /Sub Contractor C �• c Address 3tt l "j�t �<< 1 City (. �� ns Lic# 5` ! % Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />Township <br />'.RNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING # _ 2 <br />WELL # i-) -I;-/ •-M a2se t <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE Chi <br />0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />TYPE OF WELL g'HOLLOW STEM DIA. OF BOREHOLE ':3 ' MULTIPLE CASINGS? 0 YES RNO WELL CASING DIA: Z <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -10 TYPE OF CASING: 0 STEEL S PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `3 i tI t06TREMIE TYPE TO BE USED: GAUGERS NOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0. No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH 7`� ` Q ��L'$OLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS:1-0 Ca--"-' \ C -i <br />I a 33 131 Ccs I r 40: S t �- e_e �-� � ��r 1 .33l,vt e, -r ca <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that 1 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: "1 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: "1 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 />rJLF%ANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title j2 eec�T—Date <br />1tl rr CrD <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />��,� �S.I rG�,^ Date Issued `` Area <br />Application Accepted By FPL, a p <br />Grout Inspection By <br />Date /� CJ Final Inspection By --__ Date / <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />},: <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />NSATION <br /># I INVOICE <br />TION <br />