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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' , VIED <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 SAN 1 3 2000 <br />(209) 468-3449 ENVIROINMENIAL HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT / SERVICES <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 />� � k44 Li nn -e Assessor's <br />WELL Location //�� // �� Cross Street -a►Yr City / ! G Zip "I,Sp�7�= Parcel# <br />PROPERTY Owner F' Ch�K�i 1t -(p Address_7��5 i $r �J.� City Zip c7;1 e# d�y <br />ctor Address UD3 3G61 /�� City�/'� ZipLiiti Phone,#` 3 d Z2Z Z� <br />r , / 1 /�,�- ! L// 1 �, <br />Consultant / ub Contractor - Address 5 /y . ���Sut� CityS Lic# Phone# Zf&7vC),� <br />Coordinates: X Y Township. Range Section <br />WORK TO BE PERFORMED C <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />D <br />'Other: 0 WELL # 0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />/MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ?t l MULTIPLE CASINGS? 0 YES gob WELL CASING DIA: Z� <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 2 PVC 0 OTHER: C>-1 <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �S / TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: z`?es 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 66) ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "l 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 />THE <br />J/APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/ o, t i„�w� �j�,- <br />Signed x <br />Tile C>��D�.i�.�% Date <br />1 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By /' ✓ i�`�c L Date Issued / / (/V d Area 7 <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By —7,1 Date / a 7"6 ivl CJ I 4-01Lu13 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID#C R,9y� �y i -17 : / <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT //-6ECRRVICE REQUEST # 4NVOICE <br />LL <br />SR <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />