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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 />ORIGINAL <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 22i 1 k). LS e-,oLUAj Cross Street ',/1. Pttrt,b City _S,2-'LkrsajZip9V2Cg-Parcel# 117- ,36o <br />PROPERTY OwnerCOO 6.-"ThrilQ.A.Xddress 2 ity STcyJact) Zip caY.3—Phone# <br />C-57 Contractor sfEC-712-0/1/1 Address City Zip Phone# <br /> <br />.5-# q7 2 <br />LicLi7 <br />Consultant / Sub Contractor Epe.:7/74-L r-21/06I? Address /7_ T93 r4D13,.v 6XL.ACity Lc DI Phone#g6B - y g 0 / <br />GIS Coordinates: X ,Y ,Township Range Section <br />WORK TO BE PERFORMED: <br />sLN <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />a PRESSURE GROUT <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # 7 <br />WELL # <br />*Other: <br />COMMENTS: <br />7 <br />CONSTRUCTION SPECIFICATIONS TYPE OF WELL INSTALLATION TYPE <br />/1421bNITORING Lk-1461_1_0w STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />U SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />DIA. OF BOREHOLE /:3 MULTIPLE CASINGS? a YES 046-* WELL CASING DIA: ll <br />CASING THICKNESS SC,/ .2r0 TYPE OF CASING: 0 STEEL ff-P<'C a OTHER: <br />DEPTH OF GROUT SEAL 2.01-- TREMIE TYPE TO BE USED: 0 AUGERS 4141<cgE <br />GROUT SEAL PUMPED: es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 5t) - 6-1515-rrED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? )0 ( 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: "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: "/ 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 IV IN ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x Title/Company tO.0 / L- <br />MENT <br />Print Name .g1 FE:JUR P Date i7/ RECEVED E/24) <br />SITE FILE ADD ORK PLAN DATE: ki t a-1 2-oe='e, <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> Date <br />Date <br />p.a t/ V672 ce.z=. S EP 1 1 2000 <br />/11\1 JON* lJ ?...//- 00 PUBLIC . '0 Date Issued t <br />ES . . <br />41, <br />Final Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFOAMOUNT REMITTED CHECK # REC'D BY DATE _P5_112 11.11-i-SERVIGE-REQUZ_ST INVOICE <br />(1..e 4X L4 <br /> <br />,35-0/ 57 exp. WC/waiver C-57 Letter of Authorization to sign pei Encroachment d_p_sks- 5/17/00 _