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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 /> (209r 468-3449 - <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/Qr 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 Divisic <br /> Assessor's <br /> WELL <br /> WELL Location 35 5aa We inn Road Cross Street wy 33 City i;gniALLIS Zip 953aS Parcel#ass- 0160-c <br /> AA <br /> PROPERTYOwnerhirnela pore--n 1&11iylt Adddrreesso'410 W.Dvr►zgm Feerjuty -Traay_Zip`lS3oqPhone411 o <br /> C-57 Contractor C-1re11DrIJli44 �o• Address IJP OWC P't'L City�a'���tZ Zipy`I553 Lic#'i85I65Phone# 510 313- S. <br /> onsulta t/Sub Contractorcneo�aa' %-x Consv1�-&AAddress alol Webs}e/ 5�. City0aKla vN Lic# Phone# <br /> 6� sl�'663•ya <br /> 1 A+h FIooR - <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> VNEW WEL (BORING CPT,GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER') DESTRUCTION(choose type bete <br /> SOIL BORING# S B -g s d-IC, S 0- 11, S Q' I a ' S B— 13 Q OVER-BORE <br /> p WELL# <br /> RESSURE GRO <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE 6 i.'1. MULTIPLE CASINGS?1]YES XO WELL CASING DIA: N+ <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS PJA TYPE OF CASING: [I STEEL a PVC a OTHER: <br /> O VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL'�u i► i-I K 'ill TREMIE TYPE TO BE USED: AUGERS+*0. <br /> a AIR SPARGE o PUSH POINT GROUT SEAL PUMPED: )Klyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS.2 <br /> `SOIL BORING a HAND AUGER APPROX. BORING DEPTH 10* — -I O ' 0 BOLTED TRAFFIC BOK or a STOVE PIPE <br /> 0 OTHER:_G OTHER CONDUCTOR CASING PROPOSE D?_/ (if YES,list specifications here): <br /> �r' 11 .'� bo :n�S �� d:cr+t-�e�1tJ kH I-�a��ow S32v�1 �J.`tC�. (}r1 e, be '.r,G v �C <br /> COMMENTS <br /> 3 o in O one- -:n O alle.ok' Soy qn ab lbvra^'a�t�' SA- <br /> NOTE: OFFSITE BORINGS REQUIR5 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 R, <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the w <br /> for which this permit is Issued,t shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub <br /> contracting signature certifies the following: •1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califamia." <br /> TH PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By <br /> Date Issued !D Z Area <br /> Grout Inspection By "^^/-( - Date - <br /> =-- Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC» <br /> ACCOUNTING ONLY: AID'- <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVC <br /> C S? CLSED CQN Fk €3RT. <br /> S" X ,LTCEISE&101�KR_ ',: C�I11F1AS nG <br /> UNIT IV-6/23/99/sign bkpg/MI <br />