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• UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> o� 12 24 304 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 fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapt 9-111 3 and the Stand-a}rds of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location J 1 15vY1 Cross StttrreeLt _City TPuc Zip Parcel# <br /> PROPERTY Owner LtNNt<I Address I".r�1P 1'1R y(, C`ity`w+//rfv' ip i L.j Phone# <br /> C-57 Contracto PiIVA bltt Addy salvo Ir+� / ncitl,�1,� Tr•��`�� ,,� /rf,,y Lia►�5�1`IS Phana#5171c-3`�3-111 r� <br /> Consultant/Sub Contractor •(D P 1/t1Address33yl�lMlb2VlIV^0 �CItyfBmYJ�L�Uc# Phone#5J�D7b 61'N9 <br /> GIS Coordinates:X <br /> y.,Township Range Section - <br /> WORK TO BE PERFORMED <br /> ,NEW WELL/BORING(CPT,GEOPROBE,HYD��{QQP H H,H D- CR,OTHER') p DESTRUCTION(choose type below) <br /> 0 SOIL BORING l-fr a OVER-BORE <br /> W f(ll 0 PRESSURE GROUT <br /> 0 WELL# <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> '10NITORING a HOLLOW STEM DIA.OF BOREHOLE -IO MULTIPLE CASINGS?a YES 100 WELL CASING DIA:_ <br /> a EXTRACTION - LIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC G OTHER: <br /> 0 VAPOR ` V UD ROTARY DEPTH OF GROUT SEAL ltnd2TREMIE TYPE TO BE USED: GAUGERS 11HOSE <br /> p AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: 1KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING p HAND AUGER APPROX.BORING DEPTH iyu' *OLTED TRAFFIC BOX or a STOVE PIPE <br /> a OTHER:_9 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> CQMMENTS: '"ll 1 CD <br /> ro 411d', M&4 PbfL Illfug <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> S <br /> I hereby certify that 1 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: 11 certify that in the performance of the work <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors 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 /> ff,rL r� ?`ffib.4.,am [# <br /> Signed x uUr Title �1�.17 6e.)/v Sf Date 5-15-6 I <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: _ 5Iia �a l <br /> 1' DEPARTMENT USE ONLY <br /> Application Accepted By _Date Issued O'r i u Area �l <br /> Grout Inspection By - Da Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> W Remo Ow <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> V40dA WdVS' LL 6661-60-ZI <br /> Z cd <br />