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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 />l r Assessor's <br />WELL Location 301 CJ. 1` -r— f-e1M(ya-0 L -O- Cross Streeytt 5• Pj�a1wf City Zip S�KO Parcel# <br />PROPERTY Owner ���W h 4 `�'4or �0.1tOv� � Address I (moi (J✓'0.vxIGr�ro-o�d at• City L—o r] , Zip 15-V40 Phone# <br />I CSS (� <br />C-57 Contractor&�v �1 7M ress 3Q4 �t P.o / S r 1 e City at( Zip? ZSZ Lic# 683865 Phone# <br />Consultant / Sub Contractor 67 Address 310 60fd CrtY Al-c-i'O Lic# SS77 Phone# L 3/ /Md <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />> NEW WELL/ RING CPT, EOPROB , HYDROPUNCH, H D -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />ORI ' # A 0 OVER -BORE <br />O WELL # 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA. <br />co <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />A\SOIL BORING 0 HAND AUGERp <br />0 OTHER: OTHER eel M <br />CASING THICKNESS TYPE OF CASING: O STEEL O PVC 0 OTH <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes i � 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Ct <br />APPROX. BORING DEPTH p - Z O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />w NOTE: OFFSITE BORINGS R QUIRE 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, 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 />TH APPLICANT UST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />t Com► L Title vr/a✓ �� /Sr Date <br />Signed x e u, ct�� <br />SEE SITE MAP IN UNIT IV WORK PLAN DA ED: <br />DEPARTMENT USE ONLY (/ L ` <br />Application Accepted B Date Issued % �� t)U Area <br />PP p Date 2 - DD Final Inspection By Date %2. DD <br />Grout Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: �" `�`� a"�'� cu cry / <br />PCODES <br />G ONLY: AID# FACA <br />FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE P ST # INVOICE <br />� dS► Sia �4'i `��b �Drr> _7x' <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKER OMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />I <br />