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WELL PERMIT APPLICATION FORM I <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 w _ <br /> N <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 appitcabon is made in compliance with <br /> San Joaquin County Development Title VChapter -1115 3 and the Standards of�S^an Joaquin County Public Health Services Environmental health Division <br /> WELL Location 1J�%/^� �`i[n cel-.w Cross Street I k cc4w C,ty mplq,5174 Assessor's ars l <br /> PROPERTY Owner C Address2Z E- )DA 5A7 City c Zip g53yA.Phone# L�bR)831--r�QO <br /> C-57 Contractor Address 3632 Ok ac, Ctiyle- city < 4--.c► Z'p ';74ZUc#71-;SI0 Phone# �r16-� X38- 1169 <br /> SkarnC� t�. `l-�`° 916-631- 130V <br /> Consultant)Sub ContractorIt �.n.� �„� Address 316`- G.�L&C City Lt[# 55�� Phone# <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> {(NEW WELL 1 BORING(CPT GEOPROBE,HYDROPUNCH HAND-AUGER OTHER') Q DESTRUCTION(choose type below) <br /> Q SOIL BORING r [I OVER-BORE <br /> 'WELL# Q PRESSURE GROUT <br /> *Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING aliOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?I)YES VNO WELL CASING DIA 2 a <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS Scl '1b _TYPE OF CASING 13 STEEL XWC Q OTHER <br /> d VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL -3 r TREMIE TYPE TO 13E USED Q AUGERS QHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL.PUMPED a Yes A10 (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER APPROX BORING DEPTH 1154 3OLTED TRAFFIC BOX or d STOVE PIPE <br /> (I OTHER (I OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 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,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractor's hiring or sub- <br /> contracting signature certifies the following "l certify thal in the perfofmance of 1176 work for which this permits issued I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Caldomre " <br /> A PLICANT MUST CALL 48 WOR!(ING HRS!N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x to to 11 ab <br /> SEE SITE MAP IN UNIT 1V WORK PLAN DATED. a>Lo� 13 ZOV0 <br /> DEPARTMENT t15E ONLY <br /> Application Accepted By Date Issued s!Q o'U v Area Q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By gate <br /> COMMENTS f CONDITIONS. D Z Z- — O a �` '�' <br /> ACCOUNTING ONLY AID# FACt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY HATE PERMfT/SERVICE REQUEST# INVOICE <br /> vu']1 2 Z 31� <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br />