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WELL PERMIT APPLICATION F%. ,ZM 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 ,vith <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ <br />essoal s, <br />Health Div,3' <br />WELL Location 1/! S A44 mj � •• Cross Street %A City Zip Y:<.477 Parcel# <br />PROPERTY Owner 11 f> <br />Address �663.tire City Nope, Zip �3S S�Phone# 4W �iR<<' <br />�'�, �m,�, �,Li ynl Address r/S33 Iv' �1�7�en//16 o City DG/[.8✓Zip�7i'! Lict4t Y Phone# D� <br />C-57 Contractor �+ <br />Consultant / Sub Contractor Address City Lie. Phone# <br />GIS Coordinates: X <br />Y Township _;rZ Range4-7,E' Section my <br />WORK TO BE PERFORMED <br />$,NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type be!ow <br />0 SOIL BORING # Z— 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE_ OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />;807iOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />OTHER <br />CONSTRUCTION SPECIFICATIONS .�> <br />DIA. OF BOREHOLES ff�v" ULTIPLE CASINGS?OLS)NO WELL CASING DIA. Z.<^ /r <br />CASING THICKNESS .SC -4 4— TYPE OF CASING: 0 STEEI: ) PVC 0 OTHER: <br />DEPTH OF GROUT SEALS 1` re 2(,-V 01 TREMIE TYPE TO BE USED: 0 AUGERS 2(iOSE <br />GROUT SEAL PUMPED: 0 Yes r $6o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH ZSefC• c J�,80LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? >Z- ( if YES, list specifications here):,�'tf�'�itcE3 <br />7 �•. c � i � I � • c•� � •- �� ��iT�� Z �E M� 1 Ntshl � 1/� r! z • v D�� - <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 R,.iles <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 />issued, 1 shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or Sub - <br />for which this permit <br />is iscertifies issssthe following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />contracting signature t <br />WORKERS' COMPENSATION Laws of California " <br />CALL THE UNIT IV I SPECTOR 48 WORKING HRS IN ADVANCE V.11-1 FOR ALL REQUIRED INSPECTIONS. <br />_ Title/Company yk>w1`7f'�� d SEL* <br />Signed x - <br />DCS <br />Print Name <br />/�. 3fi �C Date - <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY t �` <br />v ate Issued Area <br />Y a <br />Application Accepted By r -y Date <br />Grout Inspection By Date 0 /nal Inspection By <br />1' Date <br />Destruction Inspection By,/ <br />t' <br />COMMENTS f COWITIONS: r_ .n .� <br />ACCOYJNTING ONLY: AID# .. — <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE <br />T # INVOICE <br />1;18/2000 <br />