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T <br /> 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) 468-3449 <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 /> j� Assessor's <br /> WELL Location (013 FA TICG 1416 . Cross Street p T��-r City c Zip Parcel# 0q� ��- <br /> PROPERTY Owner &bt-t II D VA O-"t�tuAddress P,0I• L7o x _7969 City ��zhk Zip 96c,I Phone# <br /> C-57 Contractor lq �YJ1► t I I Address 9rJ� t"l0wL I�G1• City M� h��+Zip_3Lic# 10 Phone# (9u 313 -S$DO <br /> Consultant/Sub Contractor rAmbrt21 E11yWIWNfti*Address 210 PcrKIAS S-1. City Sbrlbw%,L Lic# Phone# 001)935 -ii'co-o <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED (' <br /> NEW WELL/BORING(CP•T GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) W <br /> SOIL BORING# SS-S t SB -(o 0 OVER-BORE <br /> �WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ r <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z �y MULTIPLE CASINGS?0 YES 1xNO WELL CASING DIA: Imo' a <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL__L20 t70 TREMIE TYPE TO BE USED: 0 AUGERS *OSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER APPROX.BORING DEPTH 10 0 a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: OTHER CONDUCTOR CASING PROPOSED? NO (if YES, list specifications here): <br /> �1 <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: "I certify that in the performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'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 /> WORKERS'COMPENSATION Laws of California." <br /> C A Lj.,T.H E UN CTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 80%11 a <br /> Signed x Title/Company /� �^ <br /> Print Name ! RIV / Date lyL 0y <br /> PITAR <br /> DEPARTMENT USE ONLY <br /> Application Accepted By .n Date Issued s OG Area <br /> Grout Inspection Bye i1/1/�CC�ti� Date Z Final Inspection By Dater <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35-01 g1.00 lois s�q ooaoL�Sa <br /> si2000 <br />