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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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 30 t I'`'' � e " ( 2v^cA.-`k Lc� v�e- Cross Street S. Le -e- 4,1G • City L c, t Zip Parcel# ON of L -J, <br />PROPERTY Owner aevro•-N Address ?a• �X 600L/ City Zip `1'4S83Phone#i2S-Sg2-80S <br />C-57 Contractor U w Qn�kvA� ((, �j Address -0. S II City'�toZip �`�5�(Lic# 72010'/Phone# -70-7-3 74' 28 t�- <br />Consultant/ Sub Contractor lvtC Address3T)r• City C-orAa vA Lic#nO713 Phone# X16" 631- 1300 <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />Y <br />Township <br />;R.NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND AUGER, OTHER") <br />0 SOIL BORING # <br />0 WELL # M W - <br />'Other: <br />COMMENTS: <br />PE CODES <br />TYPE OF WELL <br />INSTALLATION TYPE <br />I (MONITORING <br />RHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_O <br />OTHER <br />COMMENTS <br />Rang <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />pan UJ arkP 1116��1a-ina✓�+�aiec� ll -II-- <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES tNO WELL CASING DIA: 2 <br />CASING THICKNESS'X� • `�L TYPE OF CASING: 0 STEEL J�FVC 0 OTHER: <br />DEPTH OF GROUT SEAL ! TREMIE TYPE TO BE USED: AUGERS OHOSE <br />GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH -7S' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 wirn oan joaquui �.uuiiLy -OL6 u,,.. , <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 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: "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 AP LICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x CTitle (�e.o laq 151 Date -7 - 2D07� <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued Area L, dp dU <br />Grout Inspection By Date Z �' �OD Final Inspection By-Date2 i UO <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# FACA <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER REQUEST# <br />INVOICE <br />7 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WO R ' COMPENSATION_I�ECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />