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WELL PERMIT APPLICATION FORM UNIT IV <br />v .- <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESy <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") `P . <br />304 E. Weber, Third Floor, Stockton, CA., 9520V�fti ? !�, <br />(209) 468-3450 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU ,,/�I {'(x ' �-G� le S�. NApplication is hereby made to San Joaquin Cdunty for a per onstructand/or`insfall lh�work described. Thisde in compliance wit <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Sa oaquin County Public Health Services, Environmental Health-Div <br />ealt iv`` <br />5 n. c <br />r NS <br />A Assessor's - f 6 ' 7 <br />WELL Location 1 3 3 W r11_Cross Street V _A City 5 f a C. tc T C N Zip 35 L C S Pa--- <br />CA' <br />arce <br />Siake o� CAS � <br />PROPERTY Owner N Ni E E Address City �' � Zips Phone# S <br />Kt rMARTtNE} � 1;56`10 -!phone# 313��S1C0 \ <br />C-57 Contractor D P I L1 N Cr k T E 5 1 IV (,Address) 5 C i1 � v+ C I� C k _Pcity Zip) �� S 3 Lic# <br />W�lEIA T` 'i�G'`1 I <br />Consultant/ Sub Contractor E4\1 R C N M E N l It � 5Ni�y Address � f C. t Lttt �:, l. City C R A G \" Lic# (:5 I'S C I Phone# <br />GIS Coordinates: X Y Tav:r chip Range_ __ Section_ <br />WORK TO BE PERFORMED <br />NEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />I SOIL BORING # t (' T- 3 <br />0 WELL # <br />0 DESTRUCTION (choose type below) O <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE L' i N MULTIPLE CASINGS? 0 YES 1 NO WELL CASIN DIA: 11/i <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS lel fi TYPE OF CASING: 0 STEEL 0 PVC .✓T lY1A <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T O '' I'Z 5 r TREMIE TYPE TO BE USED: 0 AUGERS (HOSE <br />0 AIR SPARGE I PUSH POINT (Gt��) GROUT SEAL PUMPED: 1 Yes 0 No (NOTE: MAXIMUM FREE -FALL DER IS 30') <br />I SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Z 5 / 0 BOLTED TRAFFIC BOX or �'•,STOVFRIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? NC ( if YES, list specifications here): � N <br />COMMENTS: THII5 CPI t_�CrtT1GtY bv�tt Lit C1� 1 /�IRC-PO;Ui40S NCAR MW -4 (NI TEAU Ch <br />CEIjrv:g Lltl�r CF LH�tRj R4.1r1Y CiiY cr �j�Ct`T�N DtNIED �1JCi<GAIHMENr <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <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 WORKMAN'S 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 />WORKMAN'S COMPENSATION Laws of California.' <br />APPLICANT MUST CA �L 48 HRS IN ADVANCE FOR ALL REQUIRED INSPEC T iONS. <br />T; I&AA � ( C: -A Date Ili] 1 0l' <br />Signed x <br />i <br />d e <br />UU <br />SEE SITE M <br />I UNIT <br />IV WORK PLAN. DATE M�tr<ttrtcit�D <br />- DEPARTMENT USE ONLY <br />Issued � <br />n � Area <br />Application Accepted By <br />V1 Date Final Inspection By <br />Date 2 2 2Z6 Z_ <br />Grout Inspection By <br />Destruction Inspection B <br />ate r <br />fJ <br />T u <br />COMMENTS I CONDITIONS: <br />S� R <br />�� `� <br />tf . <br />rl - <br />✓' � <br />� <br />✓�� <br />FAC# <br />r_ <br />w 07lrss <br />AID# <br />;ACCOUN4TINGNLY: <br />INFO <br />AMOUNT REMITTED <br />CHECK#/CASH R CD BY DATE PERMI <br />RVICE REQUE MSER INVOICE <br />Z <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />