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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH. <br /> ENVIRONMENTAL HEALTH DIVISION ("PISS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 ` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATC ISSUED <br /> Application is hemby 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 Sart Joaquin County Pubitc health Services, Environmental Health Division <br /> Assessor's <br /> WELL Location- 1312) FLst 6j 1.4rr Cross Street r�L-. City.5 Tp parcel# <br /> PROPERTY Owner �dY•�r�t� -LC_pddress 9, &x _ City «�S��t,GZ,p /5d�phone# ]a7-g6S-dZs! <br /> 7 1 94S-313-Sgoa <br /> C-57 Cantractar E.��!� „_-,Arfdrrss, H t�� Jed Caty 4 ,c Zip_ y LAc4 $S&FPhonelt <br /> Consultan 1 Sub Contractorno.`rn.,Fehf tlress��c7_&4 ass 15S -tCity.s nd Craft PhonetF�O7-9�3--Z3 6It <br /> GIS Coordinates X _ _ J Y_ _Township Range_ Secuon <br /> WORK TO BE PCRFORMI_D <br /> NEW tNELL 1 GRIN CP GEOPROBE HYDROPUNCH HAND-AUGER,OTHER,) j [�DESTRUCTION(choose type below) <br /> a SOIL BORING# 5 13 I I.. ,C $ —�f 11 OVER-BORE <br /> Q WELL# (]PRESSURE GROUT <br /> 'Other <br /> C-hMMENTS <br /> E OF WELL CONSTRUCTION TYPE CONSTRUCTIp SPECIFICATIONS <br /> NITORING (]HOLLOW STEM DI/L OF BOREHC)L r-__Z�t� MULTIPLE CASINGS?n YES Q NO WELL CASING DIA <br /> (]EXTRACTION Q AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING Q STEEL (]PC 11OTHER <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL__TREMIE TYPE TO 8E USED Ix AUGERS (]HOSE <br /> 0 AIR SPARGE XPTH P�II ,T GROUT SEAL PUMPED U Yes fl No (NOTE: MAXIMUM FREE!FALL DEPTH IS 307) <br /> rs+. �- <br /> ;KSOIL BORING a HANG AUGER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ry OTHER CONDUCTOR CASING PROPOSE07 (it YW, IM specifications here) <br /> COMMENTS 94*lied -L#, 1.e- car 9wr {t�i..F. L�:en�e- _llt�'J a aL S'a'J_��•�� Fn <br /> N TE: O FSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby carhy that I have prepared Ibis application and that the work wdl be done in accordance with San Joaquin County Ordenanets.State Caws and Rules <br /> and Regulations of the San Joaqutn County Homeowner or hcerued agents signature certifies the following 1 carofy that,n tho performance of the work <br /> for which this permit is issued,f shall noe employ persons subject to WORKMAN S COMPENSATION Laws of Cal7Mornia" Contractor's honng or sub- <br /> oontracung signature cerbries the fotlowusg Y certify that in the performance of the work for which this pemn!Is issued I shalt employ persons subject to <br /> WORKMAN'S COMPENSATION Cayes ofCelrfomha' <br /> THE PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> r <br /> Signed z Title � 'd/lf AV-4- Watq a IQf <br /> SEE SITE MAP 1N UNIT IV WORK PLAN DATED <br /> (/fit U5E DNLY .-_ �I /7/�]//Apphpt�on Accepted By ` 0-0EPARTMENT <br /> Date Issued <f I�I _�`"'I _ Area <br /> Grout lnspechon By Oate Final Inspection By Date_ <br /> Destruction Inspecnon By Date <br /> COMMENTS I CONDITIONS <br /> FAC# <br /> ACCOUNTING ONLY AI0,9 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH C ED I3Y DATE PERMITISERVICE R9QUESTNUMBER INVOI( <br /> . lJ <br /> A/0 7TI <br />