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on-1�-AL <br />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 ill] ECE V EU <br />(209) 468-3449 l� II <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV 2 _1 2p05 <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services ,10blrwP, <br />���lvcf• �dleV <br />WELL Location 1& 7 IV, ty Zip 0. <br />ci2--1 5 <br />PROPERTY Owner D,, 017 Address 103� yV• I �• h, .i D, City Zip yS'L� jPhone# cj 5S -- Cij3 C) <br />/ c <br />C-57 Contractor Address -q77-') Cityhone# <br />` [} <br />�5 / <br />Consultant / Sub Contractor C�9 mow, - l Address '571cc' r II • S y l°" k City *�1 /Li # Phone# '/,?C <br />GIS Coordinates: X Y Township Range Section <br />Wo <br />K TO BE PERFORMED <br />NEW WE /BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL # `7 - 7 0 PRESSURE GROUT <br />'Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING A,,HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5�h 0 CTYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: AUGERS /*OSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FA L DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH yS , 1 %LII 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_fl OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS:'<�u>f GvC"./l C�tr�is�i_S c/��-,��•';��/ �t,LJ �i / -s ��- <br />e <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that 1 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." Contractors hiring or sub- <br />contracting signature certifies the following: "I 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 />CALL THE UNIT IV INSPEGTO 48 WORKING HRS IN A/VANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x / G ' , Title/Compan4 6 i�'1 'I,sd- <br />Print Name IZ , , Date X/- <br />DEPARTMENT USE ONLY / Q <br />Application Accepted By Date Issued ! v Area ez <br />Grout Inspection By Date Final Inspection By Date f -10 b <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO' AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DA E <br />P QUEST # <br />INVOICE <br />b <br />l (zl <br />0 l <br />