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�= _ANAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) r <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209)468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br />Environmental Health Division. <br />Application is hereby made to San Joaquin ater 9.11r15 3eandtto the Standardsnof/San Joaquin n C my Public c Health Servicthe work described. This es. Environmental � made in compliancj �Q , O2� <br />San Joaquin County Development Title/, C-�I,,p Assessor' <br />Q� 1/IJ � jIIeL JI:�!/7 Ci �ZipParceW I <br />WELL Location y�).�,,L� rT,,l cross Street <br />�' � hone# R31- 3!5 <br />PROPERTY Owner V4/ � f:&!Kt t S N �' Address r a� o _1 2� City )N <br />�,-S <br />�' A<Addrress��2=-_z <br />C-57 Contractor tp�7 W(_l � <br />it� E� <br />up Contractof�AAQ64 - ) -I- Pin <br />GsW <br />Township Range Section <br />GIS Coordinates: X —� Y-- —' _ <br />WORK TO BE PERFORMED <br />- 0 DESTRUCTION (choose type below) <br />XNEW WELL I BORING ( CPT, GEOPROSE. HYDROPUNCH, HAND -AUGER, OTHER-) 0 OVER -BORE <br />pp <br />l- BORIN.G ( -� 0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />A'- ONITORINO <br />X-IOLLOW STEM <br />0 EXTRACTION <br />U AIR HAMMER/DRIVEN <br />p VAPOR <br />O MUD ROTARY <br />0 AIR SPARGE <br />U PUSH POINT <br />0 SOIL BORING <br />0 WAND AUGER <br />0 OTHER:.O OTHER <br />CONSTRUCTION SPECIFICATIONSr�jj I I <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: L_. <br />CASING THICKNESS `T TYPE OF CASING: 0 STEEL 0PVC- 0 OTHER'. . <br />DEPTH OF GROUT SEAL'S F`&+- TREMIE TYPE TO BE USED: U AVGERS CHOSE <br />GROUTS . EAL PUMPED: eyes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEFTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NA- (if YES, list specifications here): <br />COMMENTS: /r <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify toot 1 have prepared M15 -PIP lication and that the work will he done in accordance with San Joaquin County Ordinances, State Laws,and Rule; <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit Is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of Caliiomia:' Contractor's hiring or sub- <br />contracting signature carffas the following: "I certify that in the pedormence of the work for which this permil is issued. I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING NRS IN ADVANCE FOR ALL.REn UIRED INSPECTIONS. <br />Signed <br />Print Name <br />Application Accepted By <br />Grout Inspection By <br />COMMENTS <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />Z0 3SVd <br />/►7 <br />V;,WORKwPLAN;.;AATED :;• . � � a <br />DEPARTMENT USE ONLY SL <br />Date Issued /�/S�f!(� Area O <br />Date Final Inspection By Daite <br />Date"- <br />//. /fLM nb ii i/�y <br />AID# <br />AMOUNT REMITTED CHECK # REC'D BY DATE <br />.. NO1rO01S,30V <br />PERMIT I SERVICE REQUEST # I INVOICE <br />Tn8/2000 <br />BTTTL9b60Z TE:LT 000L/VT/TT <br />