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WELL PERMIT APPLICATION FORM <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 />UNIT IV <br />OW <br />ORIGINAL <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 6645 •‘Olittl'N 71415T, Cross Street ii 111 5r, City tictli'lleir Zip 9533o Parcel# <br />e 9) /P33 <br />PROPERTY Owner 7111frte--5 LfbJj S-401,1 Address / 5gic Som-tiq IlAte-iiisiCity GAT htlip Zip <br />. <br />Phone# <br />(,) <br />C-57 Contractor /1 /44 C(elit 4ve / Dd/wire )aress 53(40 $1, ttiOr City Slit. zip/ria Lic#in(1l Phone# ST& <br />Adovike.A • <br /> <br />Sub Contractor Eitxp ej../VigeAftuii.4,14-t- Address 400S-Aitlili (Ser--) Vit. City frock Lic# Phone# 441;7- cv <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED <br />WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />13 SOIL BORIN <br />e/ELL # <br />COMMENTS: <br />r ) <br />0 DESTRUCTION (choose type below) 'N. <br />0 OVER-BORE <br />X <br />*Other: Q\I <br />9 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />10AVKITORING 1,13-146[[OW STEM <br />0 EXTRACTION 9 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE g PUSH POINT <br />0 SOIL BORING 9 HAND AUGER <br />9 OTHER: 9 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE gi—Aiii-CIMULTIPLE CASINGS? 0 YES "t.0,1(C) WELL CASING DIA: 2---liVe-1-1 <br />CASING THICKNESS 609111544-40 TYPE OF CASING: 9 STEEL 61,13•VC- 9 OTHER: <br />DEPTH OF GROUT SEAL /0 'bs5... TREMIE TYPE TO BE USED: iO4COSERS OHOSE <br />GROUT SEAL PUMPED: 9 Yes 0.446-(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') .1N <br />APPROX. BORING DEPTH 28 .- 30 116*-- 0,13151:TED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A) o ( if YES, list specifications here): <br />• <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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/Company 97/"Pr aerdi.,;51i/tkilva2_4 SeteVg/iferAioatAiVile-/Zt <br />8).-Y-oto <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE IT / SERVICE REQUEST INVOICE <br />350 I -NW .e?: ' /387 fai.A-- iz5 sR# <br />kcov- 4/3_1(.. a,e ./ <br /> <br />1/18/2000 <br /> <br />Application Accepted By <br />Signed x <br />Print Name /OW /41;/C4ti c_ Date 0 7/2 +.01(V °Al vJ -.14"-JVA 114rien., " <br />SEE SITE MAP IN UNIT IV WORK PLAN DA ED: 2.; ,314/Jr Z00 a <br />Area e4.611 <br />Date <br />Date <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By