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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAIF JOAQUIN COUNTY PUBLIC HEALTH S'ERVtC <br /> ENVIRONMENTAL HEALTH DIVISION (,, PHsv-EH. <br /> 304 E. Weber, Third Floor, Stockton , CA., 95202 O s 19 _ _ <br /> (209 ) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATiEgVW NMENTI <br /> PERMIT / SE , , . <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 <br /> zDevelopment Tale, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> '._) I `1 % 5 ,rjp � 5 + fear 1 �v"1{ 114.? 5T� K rrwn Ql`7z0� Assessor's <br /> WELL Location r�ll 'A+ CrossStreet, 4e 9) V 2 . City Zip Parcel# <br /> PROPERTYOwneerr Im\) [)L Pol Evlt • Address Fc' 5 �k j ° 7 City J / r'uKTu/1 Zipqs` Pj Phone# ="I " Y(953yZ / <br /> C-57 Contractor / '/ 1�� � �'l t' ) / I, rl')9+ddress C •�r�'� T i}yt . City Si;LelirMJ'Zipci5rf Vc# 47L,VPhone#Ell la 3jlp yuo f' <br /> Consultant / Sub Contractor f"1 ' C Address y ° " J N ' `^� I S""� City .5fk K 7o,1DG � �' - Z Phone# ! " r' Y10 I v <br /> GIS Coordinates: X Y., Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 1 0 OVER-BORE <br /> WELL # PWAy . l�, Z IVl tnl<Sr Aluirq it) VV A0 Vv a PRESSURE GROUT <br /> 'Other. <br /> CCMMENTS: <br /> j TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> _MONITORING OLLOW STEM DIA OF BOREHOLE `5 i It??0�.1, �� MULTIPLE CASINGS? 0 YES )fNO WELL CASING DIA:�E 11 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS s"ln� TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 15fJ Pit, . 1' TREMIE TYPE TO BE USED: 4rAUGERS MHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: *Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ' ) <br /> ,] SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH :�% t Z E +- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? N ( 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 Rmes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSAT70N Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California. ' <br /> THE APPLICANT r,4UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS . /d <br /> Z T <br /> Signed x —. - ! - _,- Title . <br /> SEE SITE NfAP IN UNIT IV WORK PLAN , DATED. Laaz. L�i55 9 <br /> DEPARTMENT USE ONLY / �y <br /> Application Accepted By Date Issued fid"/ / i �9 Area <br /> Grout Inspection By ( U w.r �Q (/�. Date / Final Inspecii•on_ By Date <br /> _Destruction Inspection By Date <br /> / � <br /> COMMENTS / CONDITIONS: c�.yQp �y�o c t <br /> G � <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC !CASH I RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> SSc� I $ R ' 4d-4loj` q1*11 S R# Z11 <br /> UNIT IV - 5/99 /MI <br />