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WELL PERMIT APPLICATION FOITM 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 Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> _ Assessor's <br /> WELL Location 70 �- h e r ��✓ VV ay Cross Street `)1u n i 5lau S City 5)6(Iii tb tn Zip Parcel# <br /> PROPERTY Owner �a loco 0 01 lol and to Address 70 i E- i�a 041( V& City 5 t 14 h ZipT5.70t Phone# <br /> C-57 Contractor�dyd,(C-y 6-oi=HNi'n-w-46dress 400y N wil4a, City5}�40 Zipgjly Lic# 3Ur1Phone# 467'ICO� <br /> Consultant/Sub ContractorvLiPt <br /> ✓DAddress City Lic# Phone# <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> JL SOIL BORING# Ir, �, 0 OVER-BORE <br /> 9 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I1 MONITORING 3- v J&HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS WA- /1,4.140 TYPE OF CASING: 0 STEEL WPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T-p• / An) TREMIE TYPE TO BE USED: 0 AUGERS JJHOSE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 0 Yes RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH C) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER._0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> QVJi`u9 Cowc)uC}o,- Cegiuy 17b,- C-1 ° bOr i V,4 <br /> COMMENTS: <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: "I certify that in the performance of the work <br /> for which this permit is issued, l shall not employ persons subject to WORKERS'COMPENSATION Laws of California." 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 California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed xryl.c�y� V t, Title/Company IAA�'a k C KCf G-0 r—N V 1✓00 WI c v(�Q�, Z—t4 C - <br /> Print Name p+� i h I t C t 1 �p t/� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `' Date Issued 4 Area-1221L <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By �Date <br /> COMMENTS/CONDITIONS: ,z!K L <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />