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w, <br /> I WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) - <br />'i 304 E . Weber, Third Floor, Stockton , CA . , 95202 <br /> (209 ) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> th <br /> Application is hereby made to San Joaquin County for a permit o construct Standards of/Or San Joaquin the <br /> County scribPubled. I his Services,ets, Envion is ronmental Heade in laalfh Dince vision <br /> e Chapter er 9 1115.3 and t <br /> Development T t P is <br /> County Assessor's <br /> San Joaquin Cou y P Ass <br /> WELL Location <br /> 2085 E . Fremont St . Cross StreetLa r�e_1 St Cay Stockton zip Parcel# <br /> PROPERTY Owner MR &MR.-S - FDp Tann Address 738 P1 PaSPnn�11,1N StO Ckt oZJp 5.Phone# 474 - 0434 <br /> 3911 W. Capitol weRitySa �ra ante - 95691 =# 466270 one#9.16 371-1690 - <br /> C-57ContractoTabr n �.. n <br /> f tants . �� P <br /> Consultant / Sub Contractor WHF INC . Address P . O . Box 427 city0akdalet.ic# Phone# 848 - 4280 <br /> GIS Coordinates: X <br /> Y , Township 1 North Range 6 FaSt Section 32 <br /> WORK TO BE PERFORMED <br /> `%NEW WELL / BORING ( CPT, GEOPROBE, HYDROPU NCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br /> 0 OVER-BORE <br /> 0 SOIL BORING # 0 PRESSURE GROUT <br /> 0 WELL # <br /> -Other: CPT 1 each .;P,� <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? [ YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC 0 OTHER: <br /> [ VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [ AUGERS OHOSE <br /> [ AIR SPARGE [{PUSH POINT GROUT SEAL PUMPED: 0 Yes O No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30 ' ) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 150 f t 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CPT 0 OTHER CONDUCTOR CASING PROPOSED? ( 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 - <br /> and Regulations of the San Joaquin Gcunty. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of th 1Ki[ <br /> for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractors hiring or <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subjec�lr�7 <br /> WORKERS' COMPENSATION Laws of California. " - <br /> / (LL THE IT ' It SPPFCTOR 48 WORKING HRS IN ADVANCEt/'�� AORAALL REQUIRED INSPECTIO�N <br /> Title/Company // 66� i„/�T�LG r J7�faG' ' <br /> Signed x <br /> Print Name � V � L Date eoo� G9 <br /> SEE SITE ' MAP IN. UNIT IV WORK _PLAN DATED : <br /> 4 - DEPARTMENT USE ONLY <br /> Date Issued ( � � Area <br /> Application Accepted & J"'atow <br /> Grout Inspection By Date Date Final Inspection By SCS <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> Wool <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br />' G ro 1A I <br /> 1j18j2000 <br />