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WEUL 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 C �: ' 1 <br /> A_, 95202 �, �; � 1_ x <br /> (209r 468-3449 Z�Q�I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROtH DAT€ <br /> Application is hereby made to San Joaquin County ror a permit to construct and/or install the' <br /> described. This a IiCa[ian s3made in can fl�r � �ty <br /> San Joaquin County Development 7186.Chapter 9-1115.3 and the Standards of San Joaquin County Public Hearth Services, Environnetttal�Health Division. <br /> �J pp 9-wkh <br /> WELL.Location_ 1 6 a <br /> Cross Street ro E'✓!�'Ciry (�c� Assessors <br /> PROPERTY <br /> C-57 Contractor !!T1 P Phone# <br /> I� EL <br /> Address U OS_ � i` <br /> City (, (5fLZjp1_` 7/Lic7t� Phona �77 /00 <br /> Consultant/Sub Contraaor �7 <br /> V ress4a� S+. 5�7'( City I �'�d Lich <br /> GIS Coordinates:X PhoneOS70 X130- �31� <br /> Y Townshil3 <br /> Range <br /> RI=oRMED Section <br /> yW�O.RK 70 BE PE <br /> -NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAN <br /> �UC'ER <br /> / 0 SOIL BORING,a ' OTHER-) a DESTRUCTIONchoose <br /> { type below) <br /> 'Other: "LL Q OVER-BORE <br /> COMMENTS; a PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPl=C1FICATIONS <br /> ONt7.OR1NG OLLOW STEM <br /> EXTRACTION DIA.OF BOREHOLE �, MULTIPLE CASINGS? YES O w <br /> Q ELL CASING Dta: <br /> (]AIR HAMMER/DRIVEN CASING THICKNESS <br /> 0 VAPOR Q MUO ROTARY TYPE OF CASING; 0 STEEL <br /> 'VC OTHER; <br /> 0 AIR SPARGE DEPTH OF GROUT SEAL T REMIE TYPE TO BE USED: <br /> 11 PUSH POINT GROUT SEAL PUMPED; 'es a AUGERS SE <br /> Q SOIL BORING 13 NAND AUGER _�N�(NOTE: MAXIMUM FREE-FALL DEPTH S 30'j <br /> 0 OTHER:_ APPROX.BORING DEPTH POLTEO TRAFFIC BOX or fl STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED? <br /> (it YES,list specifications here); <br /> COMMENTS: r{> <br /> NO E: OFFSITE BORT GS REQUIRE ACCE S O ENCROACHMENT PERMITS <br /> hereby certiry that I nave prepared this application and that the work will be done in accordance with San ua <br /> Lnd Regulations of the San Joaquin County, Homeowner or licensed agenCs signature certifies the following: '7 certify that in the Aerfonr►ance of rhe wor/r <br /> again County Orginances,State Laws,and Rul®s <br /> 'Or which this pernature is issued,f shwf not employ persons sirb/ect to WORKERS'COMPE,VSA7700 Lays of Calffcmia.' Contractors hiring or Sub- <br /> :ontractfng signature certifies the following: 7 certify that/n rhe peformance of me work for which chis perm;!is issued /snail employ persons sup/est to <br /> YORKERS'C MPENSAI70N Lays of Califomia." <br /> T APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECT NS. <br /> iped x <br /> I v 1 T+tie v Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATEDi3 %��� �� <br /> DEPARTMENT USE ONLY Clq <br /> plication Accepted By <br /> rota Inspection ey ;... I _Date Issued 5 —1�—cr'7z Area C 7 S(o <br /> :� --ca Data Final Inspection By <br /> 'SUuCiFon Inspection By r Gvw Date <br /> atQ <br /> OMMENTS/CONDITIONS: i <br /> ACCOUNTING ONLY- AIC* FAC# <br /> 'E CODES FEE INFO AMOUNT"REMITTED ECKAt ASH RECZ=fVED BY DATE pER,VIIT/SERVICE REQUEST NUMBER INVOICE <br /> 1) El) CL <br /> :r57 LITCENSED CONTRA- <br /> J17 tJS'�`SIGN�3C�15�O <br /> TIT IV-6/23/99/sign bkpg/;41I RX£RS, Co.,2ENSATITON DECD?LATIO +' <br />