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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> PHS SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber, Third Floor, Stockton; CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED with <br /> Joaquin Development opment Tiitle,,oaquin Chapte 9-1115..3 and thefor a mt to cofistruct anwor Sta dards of Sari Joaquin County Pll the work uti c Healt Serviceescribed. This s Enion it.made in vironmental ronmental Heatth IDivissiion. San <br /> Assessor's 3 <br /> Joap County 2 (-' <br /> WELL Location `g-3 ilo2T Ar V ►� Cross Street Fjaf4w 57 City S OGKrOn1 Zip .Z farce!# `� <br /> i .1icFF�Ey STt rzc AI 9SZ19 Phone# <br /> PROPERTY Owner• t�A`-� (06041 �D SfLN"SS Address 303 W M6" w� City 5 dL�d Zip <br /> L 1Lf�Gls AddressSW S. klATr At/C City�GEAAtfirlhZip9 Lic# 2 / Phone#�5/6)t'o3/'' <br /> C-57 Contractor HITC <br /> Consuttant I Sub Contractor <br /> Address .......��City Lic# Phone#. <br /> Township Range Section <br /> Y <br /> GIS Coordinates:X WOR <br /> K TO BE PERFORMED .. <br /> jDESTRUCTION(choose type below) <br /> E a NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> p SOIL BORING# 1PRESSURE GROUT <br /> n WELL# <br /> •Other. <br /> COMMENTS: <br /> TYPE` OF yyELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORINGHOLLOW STEM DIA.OF BOREHOLE MULTIPLE,CASINGS?a YES ONO WELL CASING DIA: <br /> TYPE OF CASING: D STEEL. 0 PVC 0 OTHER: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING'THICKNESS TREMIE TYPE TO BE USED: ©AUGERS CHOSE <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING �HAND AUGER APPROXI BORING DEPTH fl <br /> BOLTED TRAFFIC BOX or Q STOVEPIPE <br /> 0 SOIL B ��U OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> OTHi COMMENTS: $', r�6AJ Z. a 1 CLS k 3S 2)Cf7L/ <br /> NOTE: OFFSITE BORINGS REQUIRE'ACCESS OR ENCROACHMENT PERMITS <br /> 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 worts <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of Cafifbmia." Contractors hiring or sub- <br /> "1 certify that in the performance of the work for which this pemnit is issued,!shall employ persons subject to <br /> contracting signature certifies the following: <br /> WORKERS COMPENSATION Laws of Califomia 71 T-1 ' <br /> Title S7A F Date <br /> Signed x G.�._ <br /> SEE SITE MAP IN UNIT IV WORK PLAN . DATED: <br /> DEPARTMENT USE ONLY <br /> rea <br /> Date Issued <br /> Application Accepted By <br /> � Date � Final Inspection By Date���� <br /> Grout Inspection By <br /> Destruction Inspection'By Date <br /> COMMENTS I CO IONS: <br /> Ikea <br /> ACCOUNTING ONLY: AID# <br />�i PE CODES FEE INFO AMOUNT REMITTED CHECK# RIrC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 5oz �tg �a zSFIft CC, Z <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> aI <br />