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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 99.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />I I��n Assessor's I <br />WELL Location Cro sStreet 11�rV1lH City St�GZip 952UZ parcel#Ci Q, <br />1t�n <br />City t.y <br />Phone# <br />PROPERTY Owner-V� O -CX -o Address 9c =Z <br />C-57 ContractorWoj—,� 4t5'� gb <br />1Dr-M\MAddress PO 8�x 336 City�ta VIS Zip�L�S�1Lic#7107` Phone# 707-374 -g3cTp <br />"(,�, sk4q Caold CaN,Q Dries ^-� 220793 Phone#916-631— 13m <br />Consultant / Sub Contractor �C�4't2r '�yC� I K(. Address 5� 1 2c(D City Lic# <br />GIS Coordinates: X I Y <br />WORK TO BE PERFORMED <br />Township <br />VEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />WELL # U - ld <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />'Other: <br />PE CODES <br />FEE INFO <br />( ' <br />COMMENTS: <br />RECD BY <br />DATE <br />G <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS Z �� <br />,'MONITORING <br />XOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? YES XNO WELL CASING DIA: <br />- <br />DIf 2 <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />�S <br />CASING THICKNESS ac -In ` O TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 10,6 TREMIE TYPE TO BE USED: XAUGERS OHOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH l ZD tet-• BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />O OTHER <br />CONDUCTOR CASING PROPOSED? if YES, list specifications here): <br />7 <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEKMI 15 <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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />T A P ICANT MUST CALL 48l _WORKING HRS IN ADVAN fCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x \ (0,Vlb 6('Zo ) Title P `I�tS Date Z/6y <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: Jc_mevvtb 120 <br />DEPARTMENT USE ONLY <br />Application Accepted By `tel Date Issued 0 y Area �f2 <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date ` r <br />COMMENTS / CONDITIONS: a I u N a C -k L. <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RECD BY <br />DATE <br />MI UEST # <br />INVOICE <br />o S <br />- <br />DIf 2 <br />_r <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' WMFEN5AIIU�,VLULARAIIV1v <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />