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WELL PERMIT APPLICATION FORMY( <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 4 I WD <br /> fl (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,Environ <br /> a mental <br /> s Health Division. <br /> 1034 Cev%"l �kVGnue Cross Street 114{++ 5+rice} City Tno.�y Zip'15379 Parcel# <br /> WELL Location _ <br /> l.ees4 Wed It <br /> PROPERTY Owner Wo�^d kcal C5>ra• Address 103�I Ge.. .ICitY_ 1 racy - —Z+P`35376 Phone#2D1-636- 110 <br /> 16ftsue <br /> C-57 Contractor cc.cle ���11+hAddress 3632 OMCL Grecle City Cardevo Zip`ISTY2. Lic#71TSlo Phone# X16-63$ - !116-4a <br /> Pa.v.d lUrsoypkd tiew -1Z1i <br /> Consultant 1 Sub Contractor Cw - Address 31y0�ye]d GaQ Dr, 1 T0_ City Ca,..ev- Lic# . Phone#Rt 6-631- 1300 <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPRO$E,HYDROPUNGH,HAND-AUGER,OTHER*) DESTRUCTION(choose type below) <br /> AVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> WELL# <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE E� MULTIPLE CASINGS?0 YES (3 NO WELL CASING DIA: <br /> 0 EXTRACTION ]]AIR HAMMER/DRIVEN CASING THICKNESS E TYPE OF CASING: j]STEEL []PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ;'F TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. Y Na (NOTE: MAXIMUMOFFFREE-FALL <br /> BOX ALLor O DEPTH OVE PE 0'' <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH E <br /> COND CTOR CASING PROPOSED? (if YES,list specifications here): <br /> 0 OTHER:_0 OTHER <br /> COMMENIIII3 SP 7er <br /> w <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,t shall not employ persons subject to WORKERS'COMPENSATION Laws of Califomia.' 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 Califomra." <br /> =1�PA-11ST MUST CALL 48:WORKING HRS IN ADVANCE-FOR ALLttREQUIRED 1NSPECTiONS. <br /> Title <br /> ger can 1 d� Date <br /> Signed x <br /> SEE SITABy <br /> I UNIT IV WORK PLAN DATED: g 1-Q` o� <br /> DEPARTMENT USE ONLY Area d bg <br /> Application AccepteE Date Issued—?-y---4Q - <br /> Date_ Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY-, AID# ACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# <br /> 3502 �3 8 INVOICE <br /> � �•3t oA <br /> D I]pVi , 5 <br /> C-5:7�LIGENSED CONTRACTOR Mi3ST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION. <br /> UNIT IV-6/23/99/sign bkpg/MI <br />