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WELL PERMIT APPLICATION FORM <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 />UNIT IV <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 />j _ Assessor's <br />WELL Location l it l S. F rr wx, A -e Cross Street -� J `�` City Ac v ro Zip � � % Parcel# <br />caner �C lR.olC a _Address.9744 7`14 f�.i'4,*� �'tlG City ��tk6n Zip <br />PROPERTY • ` ( 1f I_ <br />C-57ContractorA tcQ tx,1ImgG, AddressPo. L,x 2L31 City ax �uA Zip 'i S7YI Lic#I%1617Phone#1/4_46 WC? <br />Consultarft/ Sub Contractor /CA!Itl-J-- y , "!30." --Address � .j �' C City 1� Lich Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER") DESTRUCTION (choose type below) <br />Q SOIL BORING # ;-OVER-BORE <br />)( WELL # l 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />Q HAND AUGER <br />[I OTHER:_0 <br />OTHER <br />CONSTRUCTION SPECIFICATIONS �r <br />DIA. OF BOREHOLE L4 MULTIPLE CASINGS? Q YES,NO WELL CASING DIA Z <br />CASING THICKNESS '�-Ik YL TYPE OF CASING U STEEL ,f PVC Q OTHER: <br />DEPTH OF GROUT SEAL--IL4— TrZEMIE TYPE TO BE USED: Q AUGERS QHOSE <br />GROUT SEAL PUMPED: Q Yes X'No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 2.5 - 2 L _ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?! ) G (if YES, fist specifications here): <br />C u�f r <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 Rule_ <br />and Regulations of the San Joaquin County, Homeowner or licensed agent's signature certifies the following: 'I 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_" Contractor's hiring or sub- <br />contracting signature certifies the following: '1 certify that ;n the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS• COMPENSATION Laws of California." <br />CA L THj/—EUNIT N SPECTOR 48 WORKING HRS IN ADVAN.CE.FOR-ALL REQUIRED INSPECTIONS. <br />�1 / Q C- 1 's <br />Signed x `~ Iv` Tdle/Company I tC �C�:� r w <br />Print Name c_ : <br />Jtz-ri N') er'1 Date <br />,.- _...�.__....._. .... ... ...:.. _.__.. - �- � �-:�•-. - <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 0 3 15z/no Area <br />Grout Inspection By_ _Date Tinal Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDMONS: <br />ACCOUNTING ONLY: I AIOO <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT /SERVICE REQUEST # <br />INVOICE <br />3So( <br />SS ,0'0 <br />2l ftiQ <br />3 z <br />0 ZZ <br />