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� E t <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC EALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIV] [ON ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicstion is hereby made to San Joaquin County for a permit to construct and/or install work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.7 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> re <br /> Assessors <br /> WELL Location1313 �3 _Cross Streetr4 4.� City S' ^ Zip Pcet# <br /> PROPERTY <br /> Owner�4c.,�S�/✓icc� LLL Address 7W6 City 9i-r_4<..le- �jip Phones 7o7-96S-A& f ' <br /> 9tS-3(3-Sgoa <br /> C•57 Contractor / 1.^ ddress 7S0 Ho � City .%.t ZipaLic# YBSI9$Phone-9 <br /> Cansultan I Sub Contractor Cyan-�� L r++� �+n a^txCdCress t k: f <br /> GIS Coordinates:X 'y Township Range Section <br /> 'NORK TO BE PERFORMED <br /> NEW WELL! ORIN CP ,GEOPR05E, HYOROPUNCH.HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# S f3 —t 7�i..;sa; ,53 Li 0 OVER-BORE <br /> {]WELL# Q PRESSURE GROUT <br /> -Other- ! <br /> =MMENTS: ZI C Pl -So"I 6 0 <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTI Ott S PECIOCATION S <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE M LTIPLE CASINGS?Q YES a NO WELL CASING DIA; <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS OHOSE <br /> 3 AIR SPARGE APUJH�PC�II�TP/ GROUT SEAL PUMPED: 0 Yes 0 No (NOTE- MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: ,!! CONDUCTOR CASING PROPOSE 7 (it YES, list specifications here): I <br /> :OMMEN�}TS: (Towles // t i a6e_ t- 4 wr i . C 49'L <br /> � T Jc r h:rc <br /> N TE: O FSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! i <br /> I hereby certify that I have prepared this application and that the work will be done in accord ince with San Joaquin County Ordinances.State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature ce fies the following: "I certify that in the performance of the work i <br /> for which this permit is issued,i shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or suit- <br /> ;ontracting signature cerlif ies the following: 'I certify that in the performance of the work for vhich this permit is issued, I shall employ persorfs subject to ' <br /> wORKMAN'S COMPENSATION Laws of California.- <br /> THE PLICANT MUST CALL 48 HRS IN ADVANCE FO ALL REQUIRED INSPECTIONS. <br /> , <br /> Signed - Title d /�/Mbr ate <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> n f } DEPARTMENT USE ONLY <br /> Application Accepted By J (J�1 Date Issued J Jr U"" Area i <br /> Smut Inspection By to <br /> EMT"tFina inspection By Date <br /> Destruction Inspection By ate <br /> :OMMENTS f CONDITIONS: <br /> ' <br /> ACCOUNTING ONLY: AID* FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNJCASH R9CEJE0 BY DATE PERMITISERVICE R UEST NUMBER INVOICE � <br />