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WELL PERMIT APPLICATION FORM UNIT Iv <br />AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Jc <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORIGINAL <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 Devel p nt itle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br />�1. /� Assessor's <br />WELL Location�'1 ISI 4146 F,�VeI Cross Street IZ Ave City � L�YI Zip�1b2D Parcel: <br />PROPERTY Owner I"ICV-Clfn I" C. Address 10 2-2C 6. w. CrImc16( CityRrit"ORZip!77Z3 Phone# S03' 41-1 -7. 174-5 <br />C-57 Contractor 69-e(_161 PZ.Au-V461 Address'150 h owe AVE Cityp�o=-bZ ZipT`'F553Lic#45160 Phone# `iz� 313'$800 <br />Consultant/ Sub Contractor ST LORD. • Address 400S FhW'r6Ht4A&70"City witdRD Lic#fM14-2,-LPhone# `1?�• x•88' 23'Fo <br />GIS Coordinates: <br />Y <br />Township <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />Q�NELL #,4 W <br />'Other: _ <br />COMMENTS <br />TYPE OF WELL <br />eMONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />0 OTHER: <br />Range Section <br />0 DESTRUCTION (choose type belovr) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />90 <br />0�• o <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS „ <br />HOLLOW STEM DIA. OF BOREHOLES It MULTIPLE CASINGS? YES �NO WELL CASING DIA: Z <br />n AIR HAMMER/DRIVEN CASING NESSSG►-1 40 TYPE OF CASING: 0 STEEL ePVC 0 OTHER: <br />- <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />.0 OTHER <br />A.t <br />DEPTH OF GROUT SEAL 7 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />Yes 0 Ne MOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OX. BORING DEPT .BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />R CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BUKINU-b tcC�Ulmr- H` ­1`,r -00 ur% C-1110�0r•i, , .. - ' <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 Rulas <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: "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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/Company IT W r�-Pd�� t Del <br />Signed x I/ <br />Print Name I ImA � � Date <br />SEE AP. IN UNIT IV WORK PLAN DATED: " <br />DEPARTMENT USE ONLY 6 / d <br />Application Accepted By Date Issued Area <br />''. k „ _ 7 <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />inal Inspection By <br />0/•II <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES FEE INFO AMOUNT REMITTED <br />ECK # <br />R 'D BY <br />DATE <br />PE ICE REQUES INVOICE <br />3S0 <br />I <br />221 i <br />aR# O—Z <br />1/18/2000 <br />�� <br />