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5 <br /> 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, Environmental Health Division. <br /> /, 1 Assessor's . <br /> WELL Location Alm ex _t'� t'`'' AlAIS S� Cross Street �td'> a City_ S�c� t 1 _Zip Q52�2 Parcel# Is - 5G- Oaf <br /> PROPERTY Owner [i S�nG ko. Address C1 *. � I� _City/ 4t14-oc_K�n _Zip jS2b2 Phone# 201)957- $�`r`Q <br /> C-57 Contractor � e 'Drt lli sdkdrreess 3612 OM¢C Ctrc City R4,rj,��rax.sip g5'7`tlLic#7ITSIo Phone#{9i6� 938- 061 <br /> i61 <br /> Consultant I Sub Contractor &41rr-?% Address 310D,, 1-70 City .L..`Lic# SS 77 Phone# 416 6 31-1 00 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> DKNEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> p SOIL BORING# a OVER-BORE <br /> CNVELL# M w-t Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING -'HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YE5NO WELL CASING DIA: Z <br /> a EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS 5�-I,- qO TYPE OF CASING: p STEEL WVC a OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 7S r TREMIE TYPE TO BE USED: O AUGERS tf10SE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: twyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER APPROX.BORING DEPTH 10'* _gBOLTED TRAFFIC BOX or Q STOVE PIPE . <br /> OTHER:_G 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: '7 certify that in the performance of the work <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THP C T MUST CALL 48 WORKING HRS IN ADVANCE (FOR/ALL <br /> REQUIRED INSPECTIONS. <br /> Si ned x Title f o l CCS L?PL`Lc�.45Q Date S-/8/61 <br /> 9 <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED: o <br /> DEPARTMENT USE ONLY I <br /> Application Accepted By d� -511,9 Date Issued ! o Area_ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Sp W Q05 $ 514 01 O <br /> C-57-LICENSED CONTRACTOR MUST SIGN LIC SE &WORKERS'-COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />