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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made;n 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 /> Assessor's <br /> WELL Location 431 S wrl-Ae-ii-110-o_ oaA Cross Street [� City S-O��'1 rp Parterre: <br /> PROPERTY Owner Eq '%\O� EnA�4ASes Address P•O' BOX g�o7 `,''C_iity `Y�p?'� k Z;p 915a Phone# <br /> r, I l I X50 govie, _ Cay`��� Zip 94 f3 Li-# $I65 Phoney(925 313-5800 <br /> C-57 Contractor �I �'1'� � Address <br /> C ( 2 ty So cMaL Licit Phone#(10"1)933-2368 <br /> Consultant/Sub Contractors?-tM�0Y12� �y`t'�1 _Address '10 �e✓ r^S S� Ci <br /> GIS Coordinates:X Y_ Township Range Section <br /> WORK TO BE PERFORMED <br /> p�IEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH.HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> V OIL BORING# I (CPT-0 a OVER-BORE <br /> WELL# 3 CMw-2,Mw'3,Mw- f Q PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS „ A <br /> a*ONITORING(S) „eOLLOW STEM �$,-) DIA.OF BOREHOLE0� "z*�MULTIPLE CASINGS?p YES IR INO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS - S��• TYPE OF CASING: a STEEL �VC Q OTHER: <br /> t]VAPOR . Q MUD ROTARY DEPTH OF GROUT SEAL ^ S I TREMIE TYPE TO BE USED: ti AUGERS QHOSE <br /> 0 AIR SPARGE GUSH POINT C I) GROUT SEAL PUMPED: t.e&s p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING CI p HAND AUGER APPROX. BORING OEPTH -10' 1130'_a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> .3 OTHER: CONDUCTOR CASING PROPOSED? No (if YES,Inst specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I nereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances.State Laws,and Rues <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,f shall not employ persons subject to WORKMAN'S 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 /> WORKMAN'S COMPENSA77ON Laws of Califomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED <br /> ✓ED INSPECTIONS. <br /> .� Title eJ �ttU tSr Date "s — O I <br /> Signed x_�� `— -- <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 8- b - 0I <br /> PARTMENT SE ONLY Q1 '��B.�rea <br /> to Issued (J CJw <br /> Application Accepted B t <br /> Date mal Inspection By <br /> Grout Inspection By r: P <br /> Date � <br /> Destruction inspection y �� � <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> LACCOUNTING ONLY: A10� <br /> S FEEINFO AMOUNT REMITTED CHECK#ICASH C D 0 TE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> O C� <br />