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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 0 32, et— lirk5g3 Cross StreetS1-647- c-6706-5.,S) zip "i's Z4 Parcet# 070 - 31- t <br />DROPERTY Owner tliAt revi A-Le ss 382- /6f)s- <br />GIS Coordinates: X Township Range Section <br />WORK TO BE PERFORMED <br />D NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />9 SOIL BORING ti <br />at-kAA) 9 WELL ;1 <br />)T <br />ESTRUCTION (choose type below) <br />9 OVER-BORE <br />RESSURE GROUT <br />City <br />Z4Y• c- - ziple/9 Phone*P 7 7-15446 5- <br />C-57 Contractor 4d 1?VIC4-- 6)75-0 Address I/60-S" Af, X> I\LE(FOAll/ City -tix..."--t2k-S Z1t1252n6li Phone007 A.,36) <br />Consultant / Sub Contracto(.:A6 Al-ai (1-)6C) 5/-fiziltrAodress3613-4i1F City 12 3/C--12 Lic , Phol 853 --(dVe? <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />ONITORING <br />o EX TRACTION <br />9 'VAPOR <br />9 AIR SPARGE <br />SOIL BORING <br />9 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1\211 MULTIPLE CASINGS? 9 YES 9, NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL ,_VC a OTHER: <br />DEPTH OF GROUT SEAL_,4A TREMIE TYPE TO BE USED: 9 AUGERS /2.KOSE <br />GROUT SEAL PUMPED: 9 Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 00 „SeSOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED'? (if YES. list specifications here): <br />CONSTRUCTION TYPE <br />,t <br />CR)LLOW STEM + <br />HAMMER/DRIVEN <br />9 MUD ROTARY <br />9 PUSH POINT <br />9 HAND AUGER <br /> <br />COMMENTS: -roe <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />hereby c.enify that i have prepared this application and that the worx will be done in accordance with San Joaquin County Ordinances, State Laws, and Rues <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the work <br />for which this permit is issued, shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." <br />Contractor's hiring or sub- <br />:Pntracting signature certifies the following: '1 certify that in the performance of the work for wnicn :his permit is issued. I snail employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />LI Ca40&1 Title 677-§:151,57'----- Date /2 /2 51 <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Date Issued ftS/00 Area LoP -001 <br />Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: A-1( LA) /-1- 7. c!"--,t gA i,..1 -14" F _AAA. 5.1,Lerde 6.c...f.:--, q 9 i <br />Signed x <br />; <br />Application Accepted By ' <br />Grout Inspection By <br />on.s4.--1/..47(7221, <br /> <br />I FAC# <br />" ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#iCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />••cc).2, b()- (Jo C8 I /4k-- if 00 150 1 0 /07,240(i-- <br />UNIT IV - 5/99 /MI