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WELL PERMIT APPLICATION FORM UNIT IV <br />SAIF JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR =ROM DATE ISSUED <br />Aoplication 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 9-11 l 3 and the Stanaaras of San Joaquin County Public Health Seances. Environmental Health Division. <br />/' / L Assessor's <br />1 � G C� i -`l -,i c rl CrrS Cross Street tY S �l� /� ' � Parcet# <br />WELL Location �r�' Ci <br />PROPERTY Owner ,l"I l l �l r ��C it ✓ Address ( L'. )3r< ?' City k Zip hone# -2-Y2 <br />C ��' I.ti Ili- 1 � �� ✓i -r Address �� �/ik City Z5/<ftk �p��G' 7'c�C�r�f >hone7: `'i/,� 7%7­�%1L'(� <br />C-57 ontractor _ <br />Consultant! Sub Contractor C : IA ibe- � Address 6 ctly S�` �R/ /� '3417) Phone# 71 <br />GIS Coordinates: X Y <br />Township <br />WCRK TO BE PERFORMED <br />VEW WELL % ORI G ( CPT. GEOPROBE. HYDRO�PUNCH, HAND -AUGER. OTHER') <br />X1 SOIL BORING T `r <br />Q WELL! <br />Range Semon <br />Q DESTRUCTION (choose type below) <br />Q OVER -BORE <br />0 PRESSURE GROUT <br />-Other. <br />C^,MMENTS: <br />-"°E OF WEL_ CONSTRUCTION TYPE CONSTRUCTION SPECIFICaT10NS <br />_ <br />L MCNITORING HOLLOW S i cM DIA. OF BOREHOLE MULi iP' CASINGS? Q YES i] NO NELL CASING OTA: <br />G <br />0 =X T RACTION 0 AIR HAMMERlORIVEN CASING 7HICKNESS TYPE OF CASING: Q STEEL 0 PVC Q OTHER: <br />TC BE USED: 0 AUGERS 0CSE <br />(),Q <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T4k e- -REMIE TYPE <br />�. <br />p PUSH POINT GROUT SEAL PUMPED: `,$;Yes p No ;NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 AIR SPARGE <br />SAIL BORING 0 HAND AUGER APPROX_ 30RING DEPTH O BOLI D rZAF=1C 30X or Q STOVE PIPE <br />CONDUCTOR CASING ?ROPOSED7 if YES. list specifications nere): <br />(� <br />] OTHER: <br />C <br />l� <br />COMMENTS: <br />rV <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />San Joaquin County Orainances, State Laws, and Ruies <br />nereoy certify that I have prepared this awiaation and that the wont will be done in accordance with <br />the following: "I certify that in the performance of the work <br />and Regulations of the San Joaquin County. Homeowner or !icensea agent's signature certifies <br />is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br />`or wnich this permit <br />the following: 'I certify that in the aerrormance or me woAr for which :his permit is issued. 1 snail employ persons sublet to <br />contracting signature certifies <br />NORKMAN'S COMPENSATION Laws or California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />! Date - Z <br />Signed x� �i✓i'— <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />-V?7 /CI <br />DEPARTMENT USE ONLY �7 <br />Area <br />�l.L c; Date Issued 0 C , <br />>oDlication Accepted By C ) �I t <br />PGrout Inspection By �� `T v — t Date °? Final Inspection By G} Date �� <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO I AMOUNT REMITTED <br />3Sc 1 73 <br />UNIT IV - 5/99 /MI <br />=ACS i <br />CHECK :!CASH I RECEIVED BY OAi cc PERMITISERVICE REQUEST NUMBER j INVOICE <br />Sh0o <br />