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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEP�`��� �V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JAN 1 5 2004 <br /> ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> a610 q Cross Street 1-5A� c tl ar Zip`11 l Assess <br /> reef#rCG9-loo-Z <br /> WELL Location ++ yy� �'c," 1 0 c7 <br /> PROPERTY Owner O�w(1 `� CIPJV l ei r4 Addrre,,ss ll 3l kkf� Q7ltlrYgyt City _Zip IJP C Phone# <br /> C-57 Contractor Dr I —Address 17� CittY, /� / Zip9�Lic#N A Phona#L�-Zi <br /> Consultant/Sub Contractor'•' t=t(VIf,7l1 'I"Address3�.�/ (,vlflrrA�1, MI(Jd, City(FNrtsgrl LiW Phone#J�Y�J��J�+z <br /> GIS Coordinates:X - Y ,Township ASO Range J 456�Z Section <br /> WORK TO BE PERFORMED <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> SOIL BORING#Z <br /> WELL# 0 OVER-BORE <br /> *Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 9 MONITORING p HOLLOW STEM DIA.OF BOREHOLEc1q NWk MULTIPLE CASINGS?DYES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N'YW TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR IUD ROTARY DEPTH OF GROUT SEAL I SOj TREMIE TYPE TO BE USED: 0 AUGERS ;VOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: `$'1'es9 <br /> No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING p HAND AUGER APPROX.BORING DEPTH ISD 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_n OTHER CONDUCTOR CASING PROPOSED? rtC (if YES,list specifications here). <br /> COMMENTS:—Z 1-.4* k. /4 .[•p.6!1f�/19 150 , b�S <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, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> Q�/���I�� :�� <br /> Signed x �b , Title PN,6, 74 / <br /> V Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: /0-5/)z <br /> DEPARTMENT USE ONLY JZ <br /> Application Accepted By ,� Cit ��iZ Date Issued -�/✓k-1/ Area <br /> Grout Inspection By N/16/ AW 1 Date Z L,ahr Final Inspection By Azek/ DateZ I0 U <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> VNIT IV-6/23/99/sign bkpg/MI <br /> Z d W02id WVVS: L I 6661-60—Zt <br />