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J eORM <br /> WELL PERMIT APPLICATION UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <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 County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WE" Location I��u{ >.-r �Q'''(� ' _cross Street! (l.`�� P1/� Cgy �j�Gf�-Tl�+�s Tap��3 Parcel# <br /> PROPERTY Owner Luc- � Address 17,r�`�t Fb.lvfk'1U�S7�- Ciry��t''�t��—Zio Phone# tel_ <br /> C-57 Contractor t�T � Address �(50_S N ' u'1 ^e.+ty Sp1=�Li yZ�'hone#`7'�y7��b <br /> Consultant/Sub Contractor }-rG- Address Gi>4'� City Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> a NEW WELL/BORING (CPT, GEOPROBE.HYDROPUNCH, HAND-AUGER.OTHER-) a DESTRUCTION(choose type aelow) <br /> SOIL BORING# I Q OVER-BORE <br /> a WELL# Q PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING a HOLLOW STEM DtA.OF BOREHOLE '® MULTIP z CASINGS?a YES xNO WELL CASING DIA-- <br /> g <br /> IA:G EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS *► TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3C) TREMIE TYPE TO BE USED: a AUGERS aHCSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: a Yes ),No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> `SOIL BORING a HAND AUGER APPROX. BORING DEPTH 'S0 f G BOLTECI TRAFFIC BOX or a STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? (if YES.fist specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> 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 Rules <br /> anc Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/certify that in the performance of the work <br /> .or which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br /> mritracting 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 COMPENSATION Laws of California.' <br /> HE APP IC UST LL 48 HRS IN ADVANCE FOR ALL.REQUIRED INSPECTIONS. <br /> Signed x ZTitle �>� Date <br /> SEE SITE MAP 1N UN IV WORK PLAN. DATED neo.., z0 , cIC;) . <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 6 114 I9 9 Area <br /> Grout Inspection By 1 ww.. -,.-. Date S Final InspectionB- y�- Dated_ <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> FAC# <br /> 1 ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES ( FEE INFO ' AMOUNT REM=. D CHECKWCASH RECEIVED BY DATE ! PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IN-5/99/MI <br />