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WELL riERMIT APPLICATION FoRM <br /> <br />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 />Assessor's <br />WELL Location 6-02- V. 17110/ gy Cross Street /4Aillsir A City ,c,/bz,fr.,,/,.- Zip Parcel# <br />PROPERTY Owner laVetl 6EZ— Address City Zip Phone# <br />.-- <br />C-57 Contractor ea vete4 Drill Address 5 4,F2. 0,4rc dbe..414 Cityl5= Zipf:"VzLic#Pre/0 Phone/04/6*"PG? „ - <br />/ <br />Consultant / Sub Contractor trr- Address '4f'11 RAO/ a*Xity 57Z4 Lic# Phone# 7--od <br />GIS Coordinates: X Y Township Range Section <br /> <br />WORK TO BE PERFORMED <br />ti(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE c <br />XWELL # ilvd." A ( bu. z Nal. 3 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />CASINGS? 0 YES if NO WELL CASING DIA: Z. )( MONITORING <br />0 EXTRACTION <br />VAPOR <br />KHOLLOW STEM <br />0 AIR HAMMEFUDRIVEN <br />OMUD ROTARY <br />DIA. OF BOREHOLE A/ MULTIPLE <br />CASING THICKNESS 'Cif VO YPE OF CASING: flSTEEL X PVC 0 OTHER: <br />DEPTH OF GROUT SEAL r) TREMIE TYPE TO BE USED: 0 AUGERS ['HOSE <br />GROUT SEAL PUMPED: y Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or o STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): 0 OTHER: 0 OTHER <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: "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 />CA THE U INSPEC OR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company Alfra tied 6.eaCtt/tramfe <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued qz_. <br />Date (-; t- c" Final Inspection By 1 Grout Inspection By I r <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID#1 _EAC# <br />. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />; 'TO 1 11 Mt c9° I 35ScIL/ N SR# 00.2\ --S 2-0 6 <br />1/18/2000 <br />Signed x <br />Print Name Robt.4-1-- r 117 Date <br />Area <br />Date 1,,Vz /c u