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WELL TPERMIT 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 San <br /> Joaquin County Development Title, apter 9-1115.3 and the Standards ofCSan�Jo i fCounty Public <br /> ouCtyPublic Health Services,Environmental Assess r'sDivision. <br /> WELL LocationU' l <br /> Cross Streetity .� Zip Parcel# <br /> Address d " City <br /> ZipySPhone# <br /> PROPERTY Owner <br /> C-57 Contractor F��� � ��11 M <br /> 0 ` Address � o�� !) 1y+(le-_ City Sy0 ti /Zip Lic# Phone# <br /> Consultant/Sub Contractor r� (_C_ ElI ,. Address 12,71/5 60oo�i C/'� City L-,-,T_)I_Lic# 7� S� hone# <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> WELL I BORING(CPT,GEOPROBE,HYDROPl,1t� � <br /> CHYND-AUGER,OTHER')A 1� 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# I Vv 0 OVER-BORE <br /> 0 PRESSURE GROUT <br /> WELL# !k-I <br /> 'Other: 1 <br /> COMMENTS: v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> glMONITORING .[]'HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS? YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL UA— TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH (:� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: I <br /> NOTE: OFFSITE BORINGS REQUIRE CCESS 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,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors 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 /> LL NIT IV SPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x <br /> Title/Company <br /> � / <br /> Print Name 1 �F� / ,-C� Date <br /> SITE FILE ADDRESS/WORK PLAN DATE: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued �� Area <br /> Grout Inspection By Date Final Inspection By c Date l <br /> I <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S 3 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S 1334a <br /> C-57 exp._WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />