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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD / <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 NOV 0 y 2000 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicWO IlIprZ ¢gip RhEb with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ�menYY��ff 1HikAlttffFFbvvision. <br />Assessors <br />WELL Location 91b 5. 'ICEmit.(- ST. Cross Street V/61270 ST city 5t6C.IGTdr,[ zip Parcel# Iri7-I4-% <br />PROPERTY Owner JAFIAI HIA{KGL-Address <br />'.11 City Zip Phone# <br />C-57ContractoraV(2e M09f. Address7U0r N• WtL$a! k,4✓ CityS (&Md. Zip9sxSLic# d2 Phone#,/4i-lddG <br />Consultant / Sub Contractor A4E Address IFN -,Er City Lic# Phone#'1 G7 -/06/. <br />GIS Coordinates: X , Y , Township Range Section <br />WOR <br />K TO BE PERFORMED <br />KNEW WELL /BORING (CPT, OPROBE YDROPUNCH, HAN0.AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL tNG# �,9 Tu ¢ouGN E19 DOVER -BORE <br />0 WELL # PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES If. NO WELL CASING DIA: AIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: AIA <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL F,rtIIICh.- TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE &PUSH POINT GROUT SEAL PUMPED: 0 Yes V No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />,RSOIL BORING 0 HAND AUGER APPROX. BORING DEPTH IS' - 'SU r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: B OTHER CONDUCTOR CASING PROPOSED? AA (if YES, list specifications here): <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: "1 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 Califomia." Contractors 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 />WORKI <br />Signed <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: RECEIEVETD <br />� DEPARTMENT USE ONLY <br />Application Accepted By 7S�¢r9--� Date Issued li�i�o NOV Aw5 2000 <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inscection By Date P1 R1 irHEA�LTTH SERVItTCO S <br />COMMENTS/ <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # INVOICE <br />