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7-01 - P'IIQS 2 - 23PtI FR011 - - - - P - 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SRoD y l � ` f <br /> ENVIRONMENTAL HEALTH DIVISIONPHS-EHD <br /> 304 E. Weber, Third Floor, Stockton , CA ., 95202 ) /LB ;M41 7�tG <br /> (209) 4684449 smiF M • -+ 2�z/ <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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-1116.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 749 E . Charter Way Grant St . Stockton 95202 Assessor's47 - 343 - 09 <br /> WELL Location y Goss Street Gity Zip- Parcel# <br /> PROPERTYOwner Beneto , Ine . AddressP • O • Box 980220 Cii),W . Sac Zip95798PhoneP166770819 <br /> C-57 Contractor Gregg Address950 Howe Rd . CityMartinqW 9455L1111111656414&09253135800 <br /> Consultant ISub ContractorCA Geophysical ( Q&4,, P . 0 . Box 578341CityModestoLicy6506RCphone# 2095271247 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFOP,MED - "-"- <br /> 0 NEIN WELL / BORING ( OPT GEOPROBE, HYOROPUNCH, HAND-AUGER. OTHER*) 0 DESTRUCTION (choose type below) <br /> � SOILBORING # 1 Boring B - 4 DOVER-BORE <br /> •Other: WELL # 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 " MULTIPLE CASINGS? 0 YES 19 NO WELL CASING DIA:_ <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING; 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS HHOSE <br /> 0 AIR SPARGE X PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 160 Ft . 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER.0 OTHER CONDUGTOR.CASING PROPOSED? ( if YES, list specifications here) <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, / shall not employ persons subject to WORKERS' COMPENSATION .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$ issued, / shall employ persons subject to <br /> 4'VORKcRS' CGhSPeNSATIOti Laws Or Calif 'a." <br /> APPLICANT ST CALL 48 HRS IN ADVANCE///��� pppFOR ALL REQUIRED INSPECTIONS . <br /> Signed - Titley ( k.F ate <br /> SEE SITE M P IN WORK PLAN DATED May 27 , 2005 <br /> DEPARTMENT USE ONLY 1 J�1�' i ? <br /> Application Accepted By / ��� 'flY•,-�' e/S'�' ,Date Issued 07/I V/ _ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMI7TEp CHECK#/CASH RECEIVED 13Y DAT PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 0341 00 ody3� � <br /> C=$7 j ICENSED. CON'TRACT'OR MUST SIGN LICLNSE &NVOR_ TLERS' COI1 PENSp TION DECLARATION <br /> UNXT TV IF 6/23/99 /sign bkpg/MI <br />