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WELL PERMIT APPLICATION FORM <br />SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO'ni, <6.) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 /07,P0A , <br />(209) 468-3450 >47- /< °G' <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to constru= and/or install the work aescribed. This apolication is made ih5Co4pliance with <br />Assessors <br /> Township Range Section <br />NIT IV <br />San Joaquin County Development The, Chapter 9-1115.3 and the Stamm= of San Joaquin County Public Health Services, Environmental Health Division. <br />.* <br />WEI ! Location , CID Cross Street LA City ZIP Parcel <br />PROPERTY Owner T-e S't Addss 602,- ° city moct5-7Lt Phone; 31:,8- --2-`f 7 -2-- re <br />C-57 Contractor k 1) v"( Address <br />Consultant / Sub Contractor tAl' (112,,JA I4LLt. Address <br />If' City1"514-1I'L- Z14'1 IfPhone# 416 40-44a- 7 7at <br />c:ty 31-75—ph„e#(2C4-1-72,- 36 z-o Tor._ <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />g .VEW WELL BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER') <br />Q SOIL BORING at <br />WELL ft <br />'Other: <br />DESTRUCTION (choose type below) <br />"A/OVER-BORE D PRESSURE GROUT <br />COMMENTS: <br />-7"PE OF WELL CONSTRUCTION TYPE <br />MONITORING HOLLOW STEM <br />U EXTRACTION a AIR HAMMER/DRIVEN <br />g VAPOR a MUD ROTARY <br />O AIR SPARGE Q PUSH POINT <br />0 SOIL BORING U HAND AUGER <br />J OTHER: <br />CONSTRUCTION SPECIFICATIONS It <br />DIA. OF 3ORF_HOLE /01' MULTIPLE CASINGS? a YES *NO WELL CASING DIA: 2 <br />CASING THICKNESS yo TYPE OF CASING: g STEEL \(fLPVC a OTHER: <br />DEPTH OF GROW- SEAL 5 61‘,(4., 7REMIE TYPE TC BE USED: Q AUGERS ,r*C S E <br />GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH "7 BOLTED TRAFFIC BOX or Q STOVE PIPE (\- <br />CONDUCTOR CASING PROPOSED/ ( if YES. is: specifications 'here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br />; nereoy certify that I nave prepared this application and that the work will be aone in accordance with San Joagum County Orainances. State Laws. and Ruies <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "l certify that in the performance of the work <br />for which this permit is issued. I shall not employ persons subject to WORKMAN'S COMPENSAT7ON Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: '1 certify Mat in the performance of the work for wmcn rtus permit is issued. I snail employ persons subject to <br />WORKMAN'S COMPENSA770N Laws of California.' <br />THE APPUCANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title (--C— Date <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> Date Issued <br />Grout Inspection By <br />Destruction inspection By <br />COMMENTS I CONDITIONS: <br />1 <br />Signed x ' <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED 013* <br />/6V6' 76t> Area 6 7 Sle <br />Date <br />Date ct <br />Final Inspection By <br />1 <br />Date <br />FA <br />ACCOUNTING ONLY: AID* <br />PE CODES FEE INFO I AMOUNT REMITTED , CHEC CASH RECEIVED BY DATE I PERMIT/SERVICE REQUtST NUMBER I INVOICE <br />1/?4/ o a 737 <br />UNIT IV - 5/99 /MI