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WELL PERMIT APPLICATION FtRM <br /> <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 952020- <br />tv0V —7 <br />iti <br />1 4' <br />I <br />PH 4: 0 6 <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 />(ic <br />Assessors <br />WELL Location )21 „,,.)--1-1.Cross Street City :( - 7 Zip ) Parcel# <br />' <br />PROPERTY Owner ' Address 2/ 4 ‘,,,s-Z44_,Z,„ City Zip444LPhone# <br />City...T.5/-74k Zip 2:54._y(' Lic# 7,.7Phone# ./G' 22? - ,e(ec? C-57 Contractor Address /16-.$6.:2/ 1///C <br />Consultant! Sub Contractor .74 ,5,)(, 0 Lerd, „, z, Address 19(Alex c-2(cc Li c# Phone# _2(ff-1 Vc <br />(209) 468-3450 <br />GIS Coordinates X Township Range Section <br />WORK TO BE PERFORMED <br />fl_NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />0 SOIL BORING # <br />D WELL # <br />fl DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS?aYES 0 NO WELL CASING DIA: <br />CASING THICKNESS . TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> TREMIE TYPE TO BE USED: 0 AUGERS 01-10SE <br />CONDUCTOR CASING PROPOSED? 3c ( if YES, list specifications [Jere): <br />r-fc C e-e. I ,-,C" -Ye - •5s <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: "/ certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S 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 />WORKMAN'S COMPENSATION Laws of California." <br />it,---- THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x All- fi.i ( Title . . iL -z,..-=,. — /4— .i‘i-- Date /(' --0---5 <br />7 <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED73--,„ /,„, '2(7// 2 reeeT5 <br />DEPARTMENT USE ONLY ./ <br />Application Accepted By iiNtAAAect ii Date Issued 1 I )i(-1/0, Area I CW3427 <br />Grout Inspection By L. l'.--t...z-e-,A Date i )---/ z/ t"'" ; Final Inspection By (..)›-L4-1,1-e-e--x.-1 Date / -ZI S/4-' <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: IV ex4 CA/mikk..* /tervt4 ,171?--tt-ezz( k4 pH/ <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE ;..E.RIVMSE-Frrers=19.EST NUMBER INVOICE <br />5r) , o 0 . 5- 5,60A2 11 11 1 SROC 3 6 0 5TS" , <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE 8r.. WORKER.S?- GMEENSATION-DECLARATION <br />UNIT IV - 6/18/99 /sign bkpg/MI <br />TYPE OF WELL CONSTRUCTION TYPE <br />I.MONITORING 4:t HOLLOW STEM <br />EXTRACTION Q AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />CI OTHER: <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: 0 Yes El No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Cr —U BOLTED TRAFFIC BOX or U STOVE PIPE <br />C L