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WELL PERMIT 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 16 6 C Ctc._ A-tre - Cross Street ti.--)a-\ v,->-V" .5 . City S-4-ac-V--.\--o-r- Zip ciS-2-0 2- Parcel# 37-1 020 -3 I <br />PROPERTY Owner 0,-,0 c•—\ Csr-?. Address S-738 El rx,e, 31,3 , City Elk Cra--c._ Zip 5 62,-t Phone# /6)70-1 - 320C <br />C-57 Contractor Cusc4-cle rt111,5 Address 34 32 O C C CitYZAKL Circk-AL,Zip 9 6. 7412Lic# -11 770 Phonett(ilb )c 33 - I I 69 <br />G <br />Consultant / Sub Contractor CLr-t-er Address 310 601,), 170 City&LC4,,,Lic# C577 Phone# (I/6) 3 I <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED <br />11,NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br /> <br />0 SOIL BORING # <br />WELL - r- <br />a DESTRUCTION (choose type below) <br />LI OVER-BORE <br />a PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />Date <br />TYPE OF WELL INSTALLATION TYPE <br />SMONITORING 0HOLLOW STEM <br />El EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />fl AIR SPARGE a PUSH POINT <br />a SOIL BORING a HAND AUGER <br />OTHER: flOTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6" MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: 2 " <br />CASING THICKNESS 5c1, qa TYPE OF CASING: fi STEEL jia'VC a OTHER: <br />DEPTH OF GROUT SEAL 1.15 4 73' TREMIE TYPE TO BE USED: a AUGERS SiflOSE <br />GROUT SEAL PUMPED: tg:Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 66 4O gt3OLTED TRAFFIC BOX or a 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 />T P iI9ANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title 1-)a.)ect G eo.A.05 , s I- Date 5 7slo I <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 3//4.p (Di <br />DEPARTMENT USE ONLY <br />Application Accepted B700-4- L-0-f .41-1-134/1/\ Date Issued .../11 / 6i/D / Area <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ii I FA(:# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE * EST # INVOICE <br />e 066 S5 /it% . ; <br />_ _....... ......... r -rs•-•,. T C• A ."1"Tt-NTAT i',/* A D A l'TCYNT <br />C-57 LICENSED CONTRACTOR MUST SIGN LI <br />UNIT IV - 6/23/99 /sign bkpg/MI