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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) 468-3450 <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 -1706 V- 1-1 rod L Cross Street i[1 r 15 5 City Parcel# <br />PROPERTY Owner C � R ✓' s 5 14 v i^u 1� Address 706 IL F1 20124 City 0 K to ZipC15), 0 Z Phone# 4 6 S 6 7 <br />gc�7 -��LI l'� qfE <br />C-57 Contractor �a I IV�v (, o 4V10Vg-h-tAddress SGq 13 Fot7lt ll 5 IjlVd City 1;())' V) 1L Zip9 i' 4 Lie#Phone# 3V /3- <br />l Consultant/Sub Contractor M Vd4(44 6-OF-14Vir.'nA'f')Ubddressg005 IV.IN;1sa.1W11yCitySraC/tC-I Lim 0�)7Phone# 467- <br />GIS <br />67 GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />9, NEW WELL / BORING ( CPT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />Q WELL # M V I, z, 3 <br />-Other. <br />CCMMENTS: <br />TYPE OF WELL <br />CONSTRUCTION TYPE <br />{y� MONITORING <br />&HOLLOW STEM <br />] EXTRACTION <br />0 AIR HAMMER.10WEN <br />VAPOR <br />0 MUD ROTARY <br />AIR SPARGE <br />0 PUSH POINT <br />] SOIL BORING <br />0 HAND AUGER <br />] OTHER: <br />COMMENTS: <br />�i <br />0 DESTRUCTION (choose type below) 0 <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />I <br />CONSTRUCTION SPECIFICATIONS r <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: ✓ <br />CASING THICKNESS 5c U TYPE OF CASING: 0 STEEL 0, PVC 0 OTHER: <br />— 7— 9" <br />DEPTH OF GROUT SEAL 13 TREMIE TYPE TO BE USED: 0 AUGERS 0 H C S E <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') C/ <br />APPROX. BORING DEPTH &BOLTED TRAFFIC BOX or 0 STOVE PIPE �/ <br />V <br />CONDUCTOR CASING PROPOSED? V (if YES. list specfications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />nereoy certify that I have prepared this application and that the work will De done in accordance with San Joaquin County Ordinances, State Laws, and Ruses <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 WORKMAN'S COMPENSATION Laws of Califomia." 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 />wORKMAN'S COMPENSATION Laws of Califomia.' <br />g <br />THE APPLICANT MUST CALL 48 HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x itle <br />/ /� l`wl'i�U"1 ! - Date - <br />T <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY /l% / jfC� <br />Application Accepted By `-' Date Issued L° Area-� <br />Grout Inspection By _ Date L Final Inspection By Date + <br />Destruction Inspection By ` Date <br />COMMENTS / CONDITIONS: <br />AC# <br />ACCOUNTING ONLY: I AID# <br />'I PE CODES I FEE INFO I AMOUNT REMITTED I CHECK#!CASH I RECEIVED BY I DATE I PERMITISERVICE REQUEST NUMBER I INVOICE <br />UNIT IV - 5/99 /MI <br />