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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, Environmental Health Division. <br />��CC�� �52oS Assessor's <br />WELL Location GuSO 1.66V c's ZD Cross StreeFl`� FRv�[7aG,rL City 57 Z-�� Zip Parcel# <br />,�J's�8S C <br />PROPERTY Owner _0Atil Fo(.c9Ee Address 71 VJES7 F)�2v_ Rt/k� City (/INEIAh(O Zipob 3�a Phone# 7qcl" 4(7Z- <br />X146 (9r 6? �z <br />C-57 Contractor Wk(T OAZM-4T Address 3033 H77_4fLILP S% CityCar_ba✓A ZipL7`f 2 Lic#5iY971 Phone# 6 ifs - 72 7(, <br />S5 ITC 73 <br />Consultant/ Sub ContractorAhkki(Q. ddress 46oS' L a/laSou WA4 CityS7Xk-' -&J Lic#W227 Phone#Zo0 67-loob <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />lEW WELL / BORING ( CPT, G OPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />g -SOIL BORING # 1 0 OVER -BORE d <br />WELL # 3 0 PRESSURE GROUT <br />'Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />OONITORING 91 OLLOW STEM DIA. OF BOREHOLE %" MULTIPLE CASINGS? 0 YES e -&O WELL CASING DIA: Z <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS/ a UG TYPE OF CASING: 0 STEEL 0-f:'VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (,/' TREMIE TYPE TO BE USED: AUGERS OHOSE <br />O AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: R11es 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 9'S I R -60 -1 -TED TRAFFIC BOX or O STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? IVA ( 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: "1 certify that in the performance of the work <br />for which this permit is issued,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "I 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 California. •' <br />;£ LL T NIT tV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed xl Title/CompanySl,4rF&td Gr/$� ��V �d CnC!/I(lri�c[!� a�,r/tAL <br />9 , <br />Print Name ?04UL �(Sv� _Date 00 - 6,3_00 <br />SEE SITE MAP: IN _UNIT IV.,WORK PLAN; DATED: rhe/ kl�_ d- <br />DEPARTMENT USE ONLY <br />Application Accepted By t �C�LL"c Date Issued F - 7 - az) Area 0 7 <br />Grout Inspection By Date d7%/�W Final Inspection By Date <br />(la ctinn /J _. O ,2 ` Date q/w/w, % A�.n.� La , b✓_ OD -1 ._. 7L k-._ • _-t <br />MMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ERMIT / SERVICE R ST INVOICE <br />35w <br />Y7 ' <br />ht o / ' <br />CD <br />�-/M/D v <br />1/18/2000 <br />