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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 County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,EnvironmentalAssessor's Health <br /> I^ (r-7ZD F�c��iL �.) y , s S Zip �57J72 Parcel# 5�ee�` <br /> WELL Location PI.SIG "- Cross Street Q- n <br /> City� S <br /> Address Cl 1�1I City , 7 Iq <br /> Zip 5 Phorne#�26oi l <br /> PROPERTY Owner C <br /> Zip957�2 Lic# 17510 Phone#C9l6) 63$'1 !68 <br /> C-57 Contractor �Sca ck �rr ti«� Address 3632- Oms • Cti City <br /> (� r-F2y4 IN° Address3lb�Ce I) Licit ,c# 5517 Phone# % 631-1 0* <br /> Consultant!Sub Contractor 1_U .o y� <br /> Y ,Township Range Section <br /> GIS Coordinates:X _ <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type below) <br /> tEW WELL t BORING(CPT,GEOPROBE,I IYDROPUNCH, HAND-AUGER,OTHER') � d OVER-BORE <br /> Q SOIL BORING# o PRESSURE GROUT <br /> WELL# Mw-1-7 <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYP✓r CONSTRUCTION SPECIFICATIONS 2 + <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 6 " MULTIPLE CASINGS?[]YES 9NO WELL CASING DIA: <br /> EXTRACTION d AIR HAMMERIDRIVEN CASI <br /> D NG THICKNESS ' TYPE OF CASING: STEEL QVC OTHER: <br /> VAPOR 4 MUD ROTARY DEPTH OF GROUT SEA -78 TREMIE TYPE TO BE USED: GAUGERS NOSE <br /> d AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:AYes p No {NOTE: MAXIMUM FREE-FALL DEPTH 1S 3D') <br /> a SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 60+ ¢ 90+ BOLTED TRAFFIC BOX or U STOVE PIPE <br /> I]OTHER:_0 <br /> 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 ceRifies the following: "!certify That in the performance of the work <br /> s subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> for which this permit is issued, !shall not employ personwhich this permit is issued, !shall employ persons subject to <br /> contracting signature certifies the following: 'I certify that in the performance of the work for <br /> WORKERS'COMPENSATION Laws of California." <br /> T AP LIC T MUST CALL 48 WORKING HRS IN ADVANCE F(�OR IALI+REQUIRED INSPECTIONS. <br /> Title St_ LZp �4 Lt 14- Date S $ d� <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK .PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> ��- Date Issued <br /> Application Accepted By Date__. <br /> Grout Inspection By <br /> Date_ Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 8Y DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3501 <br /> (AJ QQcj vs sib OaAq 2 c) <br /> G57-LICENSED CONTRACTOR,MUST.SIGN LICENSE&WORKERS'COMPENSATION,DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />