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WELL PERMIT APPLICATIONfORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 9'5202 <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />_ G0 V D Assessor's <br />WELL Location,? 4 o aI se IQU c Cross Street City4Z1h110Q Zip '7,5-330 Parcel# <br />PROPERTY Owner q c. veaRu 57f Cv Address ?o6 -K ,50 7% City9tie-4 Aek Zipfb622 Phone#9111S�9FFk5r <br />C-57 Contractor W G s7e- X Address PO 43,x l6 Lel City W` 5--r Zip936?l Lic#g521 `kPhone#5F/L 3 73'///g <br />Consultant/Sub Contractor STem/a.S i6t0wv,<e-Xddlress33,30 4Q•vwuo•c Jo,eaCity4nt&1,<Lic# E 6a7`l�'hone#ur3P L7L^L� <br />GIS Coordinates: X _ _ , Y_ , Township Range Section <br />WORK TO BE PERFORMED <br />,KNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />0 WELL # <br />'Other: <br />COMMENTS: <br />f MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />L HOLLOW STEM <br />QQ <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />DIA. OF BOREHOLE 10 ' t MULTIPLE CASINGS? 0 YES MI NO <br />TYPE OF CASING: 0 STEEL <br />0 AIR HAMMER/DRIVEN CASING THICKNESS <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER 0 OTHER <br />0, W - <br />WELL CASING DIA: <br />0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30' <br />APPROX. BORING DEPTH 2 S -F 7 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />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 ifies the foilo � 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' CO N ATION s of a forma. " <br />LIC N MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title Al ec, <br />!a'I 4 I { " Date S OV <br />SE SITE AP IN UNIT IV WORK PLAN DATED )vIc>v-cL 12 2dCJJ <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 7-1 o Area <br />Grout Inspection By « Date 6 13 00 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE P T NUMBER <br />INVOICE <br />�,svl$�.oU <br />131+13}j <br />S noSR# oC>zzq s <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS MPENSATION DEC TION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />