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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION {PHS-EHD FILE COPY <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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> }' '! Lac. .' ��� Assessor's � <br /> WELL Location eZ Qa +] , Cross Street Lod. Ave-city cQ,,Zip Parcel# ia113-.2 0 <br /> i �6$-5311 <br /> PROPERTYOwner�P�htL a 44anSerLAddress �Sa 1 L' .31 Gity� � [�-/c� Zip tea( t�Phone#rp <br /> ('" +e L+A, Address -451, City l ZipT,66 Lic# Phone#-l&- 7;?fo- 24Iw <br /> C-57 Contractor ��� ��'-�r �f .� '�� <br /> �+ C. l�_Q_'� P a 8c, 15C-2 W� � 1sas� 7- 6 -9y� <br /> Consultant 1 Sub Contract 1 AddressCi ic# Phone#• i <br /> GIS Coordinates:X Y Township 3 N Range 7E _Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-SORE <br /> 0 WELL# O PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0�YYes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER APPROX.BORING DEPTH3!5*'' 6 f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> O <br /> OTHER:_O OTHER CONDUCTOR 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,1 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 /> x <br /> Signed x • OkiTitlelCompany l - 7 y G - <br /> >' �ao <br /> Print Nam Date <br /> SITE:FILE ADbREJf1WORK.PLAN DATE: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArft <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVIC REQUEST# INVOICE <br /> C-57 exp. WC/waiver C- 7 Letter of Authoriz tion to sign permit Encroachment docs}. 5/17/00 <br />