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�1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> 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 <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 g-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 749 E . Charter Way Grant St . Stockton 5202 Assessor147 - 343- 09 <br /> WELL Location Y Cross street CiN Zip-9Parcel# <br /> PROPERTY Owner Beneto , Inc ._ AddressP • 0 w Box 980220 cityW , Sac Zip 95798Rhane-M9166770819 <br /> C-57 Contractor Gregg Addrass950 Howe Rd . cityMartinerdp 9455L65644ane# 9253135800 <br /> Consultant / Sub ContractorCA Geophysical ( OQE.4ssP . O , Box 578341cityModestoLick.6506Rt:Phone# 2095271247 <br /> GiS Coordinates: X Y., Township Range Section <br /> WORK TO BE PERFORMED --- -' --- <br /> 0 NEW WELL / BORING ( CPT GEOPROBE, HYDROPUNCH , HANDAUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> " SOILBORING # 1 BOrin B - 4 DOVER-BORE <br /> "Other WELL # 0 PRESSURE GROUT <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING p HOLLOW STEM DIA. OF BOREHOLE 211 <br /> MULTIPLE CASINGS? 0 YES M 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 TREMIE TYPE TO BE USED: n AUGERS BHOSE <br /> n AIR SPARGE X PUSH POINT GROUT SEAL PUMPED: ayes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' ) <br /> ,[VOIL BORING n HAND AUGER APPROX. BORING DEPTH 160 Ft . 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER:.n OTHER CONDUCTOR .CASING PROPOSED? if YES, list specifications here) : <br /> COMMENTS: t/ f' r % 2G GSA — �yf,,../ <br /> -71w,6µ bor•h ) 1j- y �ilkre les ` e ve�Kz �2t L'f'� <w e . <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 or the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the work <br /> for which this permit is issued, / shall not employ persons subject to WORKERS' COMPENSAYlON Laws of California,' Contractor's hiring or sub- <br /> contracting signature certifies the following : 7 certify that in the performance of the work for which this permit i's issued, I shall employ persons subject to <br /> vVORKEr%SL�ulviPEiVSATIONLawsof Cali -a. " <br /> %- PI APPLICANT ST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. / <br /> rill, CWS/ <br /> Signed Tit[ 'I a[e <br /> SEE SITE M P IN WORK PLAN DATED May 27 , 2005 <br /> � � DEPARTMENT USE ONLY <br /> Application Accepted By ' /l`�G�/ eR jels_p'°" Date )$sued 0 7/1 �/l <br /> C <br /> Grout Inspection Bye` /1 �2�tv- Area <br /> �D/ Date� Z!?� Zl Df Final Inspection By � Data <br /> Destruction Inspection By date <br /> COMMENTS / CONDITIONS& <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> "S3 b1 s <br /> C=57 LICENSED CONTRACTOR MUST SIGN LICLNSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT TV - 6/23/99 /sign bkpg/MI <br /> E �✓t�, : '' 4cT - <br />