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WEtlL PERMIT APPLICATION*ORM 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 County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 107% N. /1n,n Cross Street L.DU+ie Ave� CityAaAe-c-a Zip%S 3i L: Parcel#,217G7C I� <br /> PROPERTY Owner/ \<Q C i u n n Addresity f'l,�. _Zip?S33 Phone#.2CQ-3.23-32 SIS <br /> C-57 Contractor G regia, AddressleS Phones s. � y/� j. E � <br /> Consultant/Sub ContractorCa.m�rja purr% ,merWAddress I i4q Coir S�-. Suite 6Ciry dw K%A CJ Lic# Phone#S70-Slsr---1£7eG <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WOR <br /> K//TO BE PERFORMED <br /> ffNEW WELL/(ORIN CPT, I�HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> OIL BORING# S 8— L B OVER-BORE <br /> U WELL# a PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 1)HOLLOW STEM DIA.OF BOREHOLE A " MULTIPLE CASINGS?1)YES B NO WELL CASING DIA: <br /> []EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS /VR TYPE OF CASING: 0 STEEL Q PVC BOTHER: <br /> o-yjr. <br /> 0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL /20TREMIE TYPE TO BE USED: Q AUGERS OHOSE <br /> OLSPARGE p PUSH POINT GROUT SEAL PUMPED: UYes pNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BORING 0 HAND AUGER ) APPROX.BORING DEPTH SSS 11B BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> a OTHER: WT'HER CONDUCTOR CASING PROPOSED? /l^ (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I 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 Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 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 California." Contractor's hiring or sub- <br /> contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Ca'ifom'a." <br /> C THE UNITjy INSPECTOR 48 WORKING_HRSINADVANCE.FOR ALL REQUIRED INSPECTIONS. <br /> �--- Title/Company 52r�� r Sf�2c�ar:J� m bril:� <br /> Signed —��''_ - <br /> Print Name Date x q: 71 r f <br /> SEE :E`1II�IAP {N�.�l)N17z 1V A <br /> WORK N AN-9 a,� r. <br /> DEPARTMENT USE ONLY G 4 y <br /> Application Accepted By \\P�11�� Date Issued a Area— <br /> Grout <br /> Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: 1;AID#PECODES FEE INFOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 6 - <br /> 1 18/20 o <br />