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WELL PERMIT APPLICATION FORM UNIT IV <br />r <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 l Cr= <br />(209) 468-3449 ORI <br />SW <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 1 , <br />WELL Location 290 N. YEiri S'trEet Cross Street North St 6–t City Zip95336 Parcel# 223--091-01 /— <br />PROPERTY OwnerBJ/ard & Ile1cEes ( Address FO Bax 1022 City mmteca Zip953 Phone# 209-239-4141 <br />C-57 Contractor V&W Teri 11 irp AddressFO DZIK 51 Cjtv1ZL0 UlSta Zip94571 Lic#720904 Phone#707-3742815 <br />Consultant/ Sub Contractor Address City Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />a NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # 0 OVER -BORE <br />WELL # 3 0 PRESSURE GROUT <br />"Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />i MONITORING f HOLLOW STEM DIA. OF BOREHOLE e " MULTIPLE CASINGS? a YES Il NO WELL CASING DIA; Z- <br />0 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 4W TYPE OF CASING: a STEEL if PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z'f r TREMIE TYPE TO BE USED: 0 AUGERS JHCSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 1-1 l { f BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Q OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? V_ (if YES, list specifications here): <br />COMMENTS: cipp att_:i� stn <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 Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "l 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 ofCalifernla." Contractor's hiring or sub- <br />contracting signature certifies the following: °I certify that Jn the pen0rmanoe of the wwfk for which this permit is issued, J shall employ pdrsons subject to <br />WORKERS' COMPENSATION Le s of California." <br />T "r,I� <br />E; PPLICA MUST ALL;41 "W fRlCll f -FfR "lf� '%1 jiG� Cy A � <br />Signed IZ0Tdle Date <br />DEPARTMENT USE ONLY <br />Application Accepted By Dale Issued <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Data <br />COM -- <br />COMMENTS I CONDITIONS: �'n A .(TLsQ- <br />ACCOUNTING ONLY: <br />AIDS FACU <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATERMIT / SERVICE REQ T.ir INVOICE <br />36ol <br />_ <br />�" <br />id b C,-421�- <br />11- 4-'ooz 09 4 <br />��,b7II ,ZW$ D:'COhl'kA I -Q, ; rtL7 4>I L E T � ? iEGLARA Ol�i <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />