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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 StandardsofSan Joaquin County Public Health Services, Environ <br />a sormental <br />Health Division. <br />WELL f <br />Location 501 bj. K -e �.ew o -H Z-1- Cross Street 5- %�C0.�''wf City ` ` Zip 57- 0 Parcel# <br />PROPERTY Owner IV WVN 4 fit¢:' Jaa%M, Address I I� 0�`0.n 0r•—City L—C, tJ . Zip 15-1,40 Phone# <br />"�' —(—} CSS <br />C-57 Contractor t'i 5c(n Zvxy a /M eipress 50 �t e -el S r, �-e City a�( Zid?SZ� Lic# 683866 Phone# Z —'s S�0 <br />-may ,Q x s Rt, 09/0 <br />Consultant/ Sub Contractor 6 0 tW—J� _"' �C•Address 3/bY � -1 Clty �^-Lic#Phone# <br />Zq <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL /(RING CPT, EOPOORING# <br />, HYDROPUNCH, H D -AUGER, OTHER') <br />HYDRO; <br />0 WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />ROIL BORING 0 HAND AUGERp <br />0 OTHER: OTHER 0Pro <br />C�Ti7 sAR <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />DIA OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH ' ly 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS R QUIRE ACCESS OR ENCROACHM NT 15ERMITS <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 fallowing: "1 certify that i ." Contractor's hiring or sub - <br />the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California. <br />contracting signature certifies the following: "1 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 APPLICAN'i UST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />CG , L� Title vt/a✓ C�-C f Sr Date <br />Signed x T 2 Grp c4, f.1 C. <br />SEE SITE MAP IN UNIT IV WORK PLAN DA ED: <br />DEPARTMENT USE ONLY , / L • <br />� JU <br />Application Accepted B Date Issued `1 �Area �0 <br />Grout Inspection By <br />Date f I D D Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: 3 ti <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />�.D { ��� dSl s3a J� �� pv GCS 27.3 5 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />