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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN ,JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-END") <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 in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Countyy Public Health Services, Environmental Health Division. <br /> AsssorWELL Location 4315 VJAki-(00 R.o a-O(- Cross Street City S`uo� Zlp Parcel# <br /> rtSt„ Q.O . aOX -7 jbb 9 City, Tom^' 2"k Zip915o 1 Phone# Com) -93010 <br /> PROPERTY Owner�1��� Address <br /> C-57 Contractoln 4 ';"I gddress 95D Ra City A } <br /> � 0"116926)3(3-560..� <br /> f4SU b�Lico — Phone#(�lo1� 93 3-2-S <br /> Consultant/Sub Contractor Cotte a eVt✓Gyyyt-TlAddressZ?O gtr nS sf• City <br /> G15 Coordinates:X <br /> Y J Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL f BORING(CPT GEOPROSE.HYDROPUNCH.HAND AUGER,OTHER? Q DESTRUCTION(choose type below) <br /> SOIL BORING# I COPT- 1� Q OVER-BORE <br /> Q PRESSURE GROUT <br /> Q WELL# <br /> 'Other: <br /> C(:AdMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> t]MONITORING Q HOLLOW STEM DIA. OF BOREHOLE 2�� MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA; �A <br /> rJ EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS II14A TYPE OF CASING: Q STEEL Q PVC Q OTHER: HOSE <br /> g VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 90' TREMIE TYPE TO BE USED: (I AUGERS Q <br /> SH POINT GROUT SEAL PUMPED: t$',es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> 0 AIR SPARGE U <br /> tg,SOIL BORING HAND AUGER APPROX. BORING DEPTH 90 Q BOLTED TRAFFIC BOX or STOVE PIPE <br /> Q OTHER: CONDUCTOR CASING PROPOSED? 1-40 (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have preoar6d this application and that the worts 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,I shall not employ persons subject to WORKMAN'S COMPENSATION taws of Califomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for wh/ch this permit is issued. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Lays of Celifomia.' <br /> THE APPLICANT <br /> pMUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> C�.T9 Title e �P � I <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED <br /> PA ENT SE ONLY <br /> Date Issued (�V fact <br /> Application Accepted By4 Date <br /> Grout Inspection ey ate Final Inspection By <br /> Destruction Inspection By Date - <br /> COMMENTS!CONDITIONS: <br /> FACS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/ ASH RECE ED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />