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0 NEW WELL / BORING (CPT, GOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />A,SOIL BORING # <br />0 WELL # <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br />WELL PERMIT APPLICATION FuRM 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) 468-3449 <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 />WELL Location / Wel. '('..Cross Street /11,44A-- City ESCO-4" Zip <br />I- /2z$-<.Address_, 2 7 ,_'''-,/}',4)77,' City 7C-#4--6;"- Zip5-720 PROPERTY Owner <br />C-57 Contractor (iti-ao Address grati --..e-0.771fiele City5"41-6. Zip Lic#74g31/2-Phone04-)5n .21_2. Z- <br />444Wlialr Address ,XS--/e)' a&ar141)/Cityirle14%- Lic# Phone# ze9 Consultant / Sub Contractor <br />GIS Coordinates X , Township <br /> <br />Range Section <br /> <br />Assessor's <br />Parcel# g3f <br />Phone# <br />WORK TO BE PERFORMED <br />TYPE OF WELL INSTALLATION TYPE <br />IlasyONITORING p(HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR D MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />fl OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE F: MULTIPLE CASINGS? 0 YES fl NO WELL CASING DIA: — <br />CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC fl OTHER: <br />DEPTH OF GROUT SEAL (7/0 TREMIE TYPE TO BE USED: 0 AUGERS POSE <br />GROUT SEAL PUMPED: 0 Yes C4Io (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 17 /6 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <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: "/ 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." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />PPLICA MUST C LL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSP CTIONS. <br />Date <br />SEE SITE MAP IN 'dNIT IV WORK PLAN DATED: <br />Signed x Title <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued 3 -7 --oo <br />Final Inspection By <br />3 —7 - a o L- 0 e A2fix <br />Arear.,_ <br />Date Co Date <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT / SERVIC ST # <br />3 57.) 1 rt - 8-, -- .9- S7,,, C.. Ce 3/7 /R# <br />C-57 LICENSED LICENSED CONTRACTOR MUST SIGN LICENSE &WORKFRSGOMPENSATIONtARATJON <br />UNIT IV - 6/23/99 /sign bkpg/MI