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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 />' c c j Assessor's n <br />WELL Location �� V`-) • Ke fe ., Lard _Cross Street S• Lee- � City L oc� Zip Parcel# ` p, <br />PROPERTY Owner Cf P-vrOv1 Address �� K u,oq City,aK Rc,. marN Zip X44 83'lPhone# <br />C-57 Contractor �t`llvv',f�IuC. Address �. C) ��K CityRtoU15 Zip1C14S c#�W�6fPhone#7!;7-37422,rS <br />/� �� ((,, �� II �/ II //�� 1�4 <br />Consultant/ Sub Contractor6e-A 2C --R t,a,� `vtG. Address 3l6 1 ��old la!2* pr • City va Lic#2zo-793 Phone# Q hb 631- OCo <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />Y <br />Townsh <br />-(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />0 WELL # Mw - 1 tM ti" <br />"Other: r <br />COMMENTS: s < icr� Ce C' �ttan VJoc � an 4vr Kv% <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />'HOLLOW 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 />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />I- II -10 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g It <br />MULTIPLE CASINGS? O YES "0 WELL CASING DIA: Z v <br />CASING THICKNESS5 . q0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER. <br />DEPTH OF GROUT SEAL !9 1 I TREMIE TYPE TO BE USED: AUGERS OHOSE <br />GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH S r 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PLKIVII 15 <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: "1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />TH PPI NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />Title l Date 1---7-2000 <br />_ Lq <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />W <br />E <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued v0 AreaL-"n U <br />2_ 0Final Inspection B Date <br />Z �� <br />Grout Inspection By Date P Y <br />Destruction I <br />COMMENTS / CONDITIONS <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />SERST # <br />V E <br />INVOICE <br />p <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' 5A110N IYECLAKA11V1N <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />