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r r <br /> WELL PERMIT APPLICATION FORM UGIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHDr') <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pe-milt to construct and/or install the wort described, This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-111115..3 and the Standards off�$On.Joaquin County PuW;c Health ServGi;cees,Environmental Health Division.J <br /> WELL Location 2Z �Z\� rlwl� ` l crass Street..AzJL7� City _ZP—!� �P —6 )-1 2— <br /> ap <br /> PROPERTY Owner 0T k�i cc N �Addr°'s�00 ���✓ � C'� �� Zp 0 Phoned_ L r �`� <br /> act <br /> C-57 Contractor to <br /> fxd" <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Rsnge Section <br /> \WOORK TO BE PERFORMED <br /> rIEy11 WELL/BORING(CPT,GEOPROBE,HYDROPUN 1•t,HANOAUGER.OTHER") Q DESTRUCTION(choose below) <br /> ORE <br /> / \ <br /> ,g-SOIL BORING# j o a PRESSURE GROUT <br /> Q WELL# <br /> 'Other- <br /> COMMENTS: <br /> OtherCOMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING a HOLLOW STEM DIA OF BOREHOLE 2// MULTIPLE CASINGS?a YES ONO WELL CASING DIA: <br /> 3 EXTRACTION a AIR HAMME-R/DRNEN CASING THICKNESS TYPE OF CASING: O STEEL Q PVC G OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL/��i'REMIE TYPE TO BE USED: Q AUGERS /$HOSE <br /> p AIR SPARGE ,�-PUSH POINT GROUT SEAL PUMPED. Q Yes U40 (NOT>;: MAXIMUM FREE-FALL DEATH IS 30') <br /> Q SOIL BORING j]NAND AUGER APPROX.BORING DEPTH �O fl BOLTED?,PAFFIC BOX or Q STOVE PIPE <br /> 1]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 Courlty Ordinances.State Laws.and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agents signature certifies the following: "t certify drat in the performance of the work <br /> for which this permit is issued,l shall not employ persons subject to WORKMAN'S COMPENSA170H Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following:"I Certify that fn 1fie perforr lance of the work for which this permit is issuad.l shall emPICY persons subject to <br /> MRKMAN'S COMPENSAT70N Laws of California,' <br /> THE APPLICANT MUST CALL 4S HRS IN ADVANC8 FFOR ALL REQUIRED INSPECTIONS. Q <br /> S;gned x - <br /> Title r-7�A <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �IMnA UJBy � )Q� Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Dest=!ion Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC"CASH RECEIVED EY DATE PERWTISERYICE REQUEST NUMBER INVOICE <br /> t:y <br /> uQfAgqa0 q 335 <br />