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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) 468-3449 <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 with <br /> San Joaquin Count D vetopment Title Chapter 9-1115 3 anj tine StarLdards of San Joaquin County Public Health Services, Environmental Health Division <br /> d r /� ` Assessors <br /> WELL Location Cro s Street �tarYttq City aCnGK�r� Zip 95 HOZ Parcel#G <br /> PROPERTY Owner ( C� Address rr�a City ipl>hone# <br /> C-57 Contractor WOof�4 'DLLjtkr'hAddress O $a '336 Caty o Vt �— Zip����IL�c#�I 1 -Phone# 7D7-3-7'� '� <br /> �} StG� Gala co' Dr+K {�,o+cly <br /> Consultant/Sub Contractor r-f��,Cin_ �►tC Address_ S��ic 210 City�Gor��w- Li -Z,0713 Pnone# 916-631— �3� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br />*EW WELL/BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER') DESTRUCTION(choose type below) <br /> 0 SOIL BORING# D OVER-BORE <br /> %NELL# U- 10 0 PRESSURE GROUT <br />'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,'MONITORING HOLLOW STEM DIA OF BOREHOLE 8" ,.MULTIPLE CASINGS? 0 YES ;00 WELL CASING DIA <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS-51-n `Lr✓ TYPE OF CASING 0 STEEL 81FVC 0 OTHER <br /> 0 OR 0 MUD ROTARY DEPTH OF GROUT SEALU G ETREMIE TYPE TO BE USED X.AUGERS DHOSE <br /> SPARGE 0 PUSH POINT GROUT SEAL PUMPED WYes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX BORING DEPTH ZO BOLTED TRAFFIC BOX or D STOVEPIPE <br /> 0 OTHER 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 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, l shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractors hiring or sub- <br /> contracting signature certifies the following "l certify that in the performance of the work for which this permit 1s issued l shall employ persons subject to <br /> VVORr ERS COQ IDENSATIOAI Laws cf Califollne <br /> T A P ICANT MUST CALL 48y WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x <br /> C0", 14Lo , Title_�P-ate S� Date ZZ C1b <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED Novewlb� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By l Date Issued C) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS R-t l d 7 i <br /> COUNTING ONLY AID# <br /> CODES FEE INFO AMOUNT REMITTED 4CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �� 0 5 D <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />