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WELL PERMIT APPLICATION FORM <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,r ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />9. 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 n San ,Jnquin County evelopment Title, Chapter 9-A115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. h ti-(15 tu kv ir.r T <br />WELL Location —N Cross Street C.. AA. d1L v City Lc) 1 Zip <br />it, 59 Tric3p,w ro..) e„5D <br />A <br />c.AN Tr; A alo c y ParceItto Assessors 's5 5 <br />PROPERTY Owner OA Address 2- I C.A L 11‘) City i(307 Zip 55%?1iQPhone#(.1951c, 7-933(1.; <br />-11 6 Ail 44.4-1 .) C-57 Contractor WiS1- 146 2- M 01- Address 5.;?rW9 F(42-c)vit:,/ YI 40 City Cc, RCX.../A Zip 95 7 YJ Lic#55V9 7i Phone# 91(0(3 .3S-5 6/3 <br />Consultant / Sub Contractor 1)\it)i.'ict.,) Eilv;farf- '6 Address 9 c G5 A ), /.15:-,,A City 3-foc.i ior LiC# b412-2- Phone# 7 <br />GIS Coordinates: X , Township 3iv Range Section <br />ORIGINAL <br />WORK TO BE PERFORMED <br />?g•JEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 SOIL BORING # <br />)3,WELL # M c w- ,P//P/ P7 /7 <br />COMMENTS: <br />*Other: <br />O DESTRUCTION (choose type below) \ <br />O OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />,VONITORING .LLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />O SOIL BORING 0 HAND AUGER <br />a OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE -n(44 MULTIPLE CASINGS? 0 YES <br />CASING THICKNESS Sc i.-10‘,7t TYPE OF CASING: 0 STEEL VC <br />v. F ,Ak • iu DEPTH OF GROUT SEAL 5 cs- D5(,,TREMIE TYPE TO BE USED: ,-1!KAUGERS [NOSE <br />GROUT SEAL PUMPED:,AKYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH F &4- 'BOLTED TRAFFIC BOX or 0 STOVE PIPE ' CONDUCTOR CASING PROPOSED? b., G ( if YES, list specifications here): <br />0 WELL CASING DIA: <br />OTHER: <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 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 />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 />WORKERS' COMPENSATION Laws of California." <br />-1HE <br /> APPLICANT MUST CALL 48 WORKING HRS IN AD NCE FOR ALL REQUIRED INSPECTIONS. <br />6-tki----------(I, n r ) Title OSQC T CPC" 09/;TDate 03.- , -- - <br />SEE SIT A IN UNIT IV WORK PLAN DATED: nq)d V <br />DEPARTMENT USE ONLY <br />3 -.3---o <br />Date <br />Date <br />V <br />' ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERM - - 'is.— - # <br />550 ‘ /AL) 'E ll 131.3 lei 3-g) -.• 22-12 , <br />Signed x Mil <br />L-/ LILLINSLI) WNII(AU[OR MUST N LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued <br />Final Inspection By 1•°77. Tapm <br />Area 419