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WELL PERMIT APPLICATION F&-?,M 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) 468-3449 <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 viiz;1, <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Envi Ase onmentssoal s _a!th Div,s,cr <br /> WELL Location qty $ ��i�t �* Cross street 13 (--Ae- city f�l/s.v z/� ZIP ?5371 Parcel# <br /> _ r x'35 S�Phone <br /> Address �iZ/665.�C t-�City/�O11L31u Zi p <br /> PROPERTY Owner_��n �•�`�� �-- <br /> C-57 Contractor <br /> r �rncx . �,/Lo_�NGAddress ?333 1�• Mme:>e•�/lc� City 5,%C,/[A�Zip zi'� Lic lv7 fid' Phone- ?0 tee!-�'Zct <br /> consultant/Sub Contractor <br /> Address City Lic# Phone# <br /> GIS Coordinates:X <br /> Y ,Township f Z� Range Section 0tl <br /> WORK TO BE PERFORMED <br /> 0 DESTRUCTION (choose type belo,:j <br /> ,ZNEW WELL I BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 OVER-BORE <br /> 0 SOIL BORING# Z- 0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z•t l! <br /> MONITORING 10LLOW STEM DIA. OF BOREHOLES.d/U" ULTIPLE CASINGStot 11 WELL CASING GIA <br /> 1. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS .Sc c� 4' TYPE OF CASING: 0 STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-5.0 r�2�'o TREMIE TYPE TO BE USED: 0 AUGERS , c,S- <br /> MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes r p INo (NOTE: <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Z!ccf' SC•c' Jt80LTED TRAFFIC BOX or 0 STOVE PIPs <br /> 0 OTHER <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here):-:!R- <br /> __— c'Shitc�s <br /> 0 OTHER: <br /> it -" Z .� iC G•c:� <br /> cf. (o•C o <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ules <br /> I hereby cedions of theaSa prepared <br /> Counthis tyl'Homeowcation nehor I cen ed geat the work will nt's signatudone in re certifies theccordance tfollowing: "/certify that inuin County 'the performance nances, State f of the s and work <br /> and which <br /> at <br /> for which this permit is issued, 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or s�:e- <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 /> CALL THE UNIT IV I SPOOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company <br /> Signed x - <br /> Date /Z <br /> Print Name <br /> i JX %�' DC) <br /> SE_ E SITE MAP- IN UNIT IV WORK PLAN DATE_ <br /> DEPARTMENT USE ONLY Z <br /> ate Issued Z� Area <br /> Application Accepted By v y Date Y a <br /> Datfinal Inspectio <br /> Grout Inspection By <br /> e n By <br /> Destruction Inspection By Date� r <br /> COMM TS/CO (TIONS: cr/- <br /> c <br /> ACCO NTING ONLY: AID# µ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE Rt <br /> 9,9 o <br />