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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 San <br />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 />WELL Location C{23 A-10Q7I4 N1AD(S#AI 4VfA1UC Cross Street rEEMOINI'i ST. city SLOCxT01t1 Zip 9_5202 Parcel# i <br />JEFr�ZEy Sf£ r2o <br />PROPERTY Owner(ilAx ('IffVIZO14T c� 5ETNwSS Address 32°3 1�f• MA W LaAJE City SToC�to� zip 9sZ19 Phone# <br />C-57 ContractorMITCUCGL biQL W11- AddressS3tb 'S. WAlr AVC • City �ACit?M We Zip %S-Fj,o Lic#�2 / Phone#6/3.!''Sl <br />Consultant / Sub Contractor Address City Lic# Phone#, <br />GIS Coordinates: X , Y , Township Range Section <br />K TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 'DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # `RPRESSURE GROUT <br />'Other: <br />COMMENTS. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />CHECK # REC'D BY <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />_0 OTHER <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here):JN <br />c <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 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,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following:"/ 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 />Signed <br />Title S-IAFr C Iktoc IS T Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / C07I�10NS: 14147 1/ <br />DEPARTMENT USE ONLY / <br />C. Date Issued 10 ` Z /'Z�U Area V Z <br />Date / Final Inspection By Date <br />Date <br />,S qYn\in��LJ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />P / SERVIC ST # INVOICE <br />i� <br />�` <br />G57 LICENSED CONTRACTOR MiI'F'SiGI-LI"BcVPitS' C <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />