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A <br /> 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 <br /> War a permit to construct and/or install the work described. This application is made in compliance with <br /> Assessor's -a30-0 <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County/Public(Health Services,Environmental Health Division. <br /> WELL Location2 L. I . �Gl Cross Street ^r K /^ <br /> ZCity Td <br /> ren ZiP �2� Parcel# �6 <br /> AV<. Slau��o,.Zip SSp YPhone#201^�tiF' y�3' <br /> PROPERTY Owner �Cr..�ra <br /> 1 Z�S Address 2150 Lrw E Ada^[ Cily <br /> 9 O City v ,n.e lZip9 V03Lic#_6564u1'Phone#`/ty�3�^�� <br /> C-57 Contractor �^,5 —Address_ fa — CL <br /> l. Ij `no�rt1^"Adtlress 9'fa�tlrGi�l✓•• City Mme.Lic# =Phone#7n-r-73L13(s} <br /> Consultant/Sub Contractor �^ ! �' <br /> Range Section <br /> GIS Coordinates:X y.,Township <br /> WORK TO BE PERFORMED <br /> �DESTRUCTION(choose type below) <br /> eEW WELL/ ORING O'GEOPROBE,HYDRQPUNCH HAND-AUGER,OTHER') 0 OVER-BORE <br /> SOIL BORING# PT—L 0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI'ATI MUS MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 MONITORING 0 HOLLOW STEM <br /> DIA.OF THICKNBOREHESS <br /> — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_ <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL l+^^� TREMIE TYPE TO BE USED: �,Ati6Ei36/yt$HOSE <br /> GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 AIR SPARGE :PUSH POINT r <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 12c;pCONDUCTOR CASING PROPO ED (if YES,list specifications here): <br /> 0 OTHER: O OTHER <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and R <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: I caRl/y that/n the eAormance of the <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or 0 <br /> contracting signature certifies the following:'1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to� <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> y� .:� f� 1� <br /> Signed z =f Title/Company - ! ��1 �� °^�^ <br /> Print Name Sc l74 <__L_; S _Date 4) LAI' <br /> I SITR,'MAP IN UN4 <br /> DEPARTMENT USE ONLY <br /> o Date Issued 1 o O� Area <br /> Application Accepted By Date <br /> Grout Inspection By V o <br /> �� <br /> Data O Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUN7T�REMITTED CHECK# REC'D BY DATE PERMIT I SERVICEEQUEST# INVOICE <br /> 3SCJ ( �g`I.00 I �j5`S <br /> 1/18/2000 <br />