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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 C:Opy <br /> NON REFUNDABLE PERMIT EXPIRES l YEAR FROM DATE ISSUED application ss made in compliance with <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This app <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> filth Division <br /> �J 7 f f A(,I _Zip 53 Parcel# Od l c-Ja i <br /> WELL Location_D Li 1�YI e � _Cross Street -sgd Cdy�� <br /> rr, ! <br /> y U i,, i-�%v' Address City Zip Phone# <br /> PROPERTY Owner {/, p �f� �},! G <br /> C-57 Contractor r c - 1 Address Lc,,-, t �� W. City 7'�Z`PI`1�Lic# IGS Phone# !2iz 3 _ <br /> J,�_�l�/� z <br /> Consultant lSub Contractor�� �? JirJ(Itja�WQ Address jL of rWYI f City LES <br /> 'i}t 550, �1�7��� <br /> GIS Coordinates X <br /> ` Y Township Rang Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) 0 DESTRUCTION(choose type below) <br /> JQ:POtL BORING# DOVER-BORE <br /> D PRESSURE GROUT <br /> 0 WELL# <br /> 'Other <br /> COMMENTS <br /> TYPE L INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA OF BOREHOLE H M n MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS_ame TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR VMUD ROTARY DE=PTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS WOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED XYes D No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER��0 OTHER CONDUCTOR CASING PROPOSED 1ZL (if YES list specifications here) <br /> COMMENTS 2 <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 agents signature certifies the following "t certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractor's hiring or sub- <br /> contracting signature certifies the following "!certify that in the performance of the work for which this permit is issued t shall employ persons subject to <br /> WORKERS COMPENSATION Laws of California ' I#r— � S <br /> al _ =; 3I�C > '�Nltt; atI — I —wr ani <br /> ! t+ <br /> �� Date !Z ~1 2 <br /> Signed x Title �� � -- , <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED l+� sso2 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By­ L— Date Issued, / / 7` _ _ Area <br /> Grout Inspection By <br /> Date Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY All D# <br /> . PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 00.E 13 <br /> 0 AM <br /> UNIT IV-6/23/94/sign bkpg/MI <br />