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WbeL PERMIT APPLICATION•flORM 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 /> 11 Assessor's <br /> WELL Location/'00 LJ, L-, %,, A v e- Cross Street/V• Main City/`1c;rt' =A Zip 533Parcel#cX17 L?LL�l <br /> PROPERTY Owner A.,% kc C Address li4kL tCou;jc Aug. Zip U-3.3(cPhone#,)DI-$a3-32KS- <br /> C-57 ContractorG r e• r;I I i v, Address 9 J&- /-fie ux �off cA CityZip2VSS 3 Lic#��Phone#`/�S-�i3-J-YCCfl � <br /> / Su,•� Q <br /> Consultant/Sub ContractorCcar-ILr-+,c. knv,,- .,,,e,,Wdress/may G/+�h +. city C�kKla Lic# Phone#S/0-5QC-07CG <br /> GIS Coordinates:X 'y Township Range Section <br /> WOR <br /> K TO BE PERFORMED <br /> R tEW WELL/4jORING(CPT,�jQ�PROBHYDROPUNCH,HAND-AUGER,OTHER.) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# SIZ-.2. S 8-3 . S Q Q-S, S f3-(� Q OVER-BORE <br /> B WELL# Q PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING B HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?Q YES B NO WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL B PVC BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL A6111111kD TREMIE TYPE TO BE USED: a AUGERS OHOSE <br /> a AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: Q Yes 11N o(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING Q HAND AUGER APPROX.BORING DEPTH VU- B BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: w6THERse CONDUCTOR CASING PROPOSED? /VA (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I 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: "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 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 California." <br /> ALL THE UNIT IVJNSPEr.TOR 48 WORKING HRS IN,ADVANCE FOR,ALL REQUIRED INSPECTIONS. <br /> Signed Title/Company.S'e#,)J ,r s GPcforil-�-10 cc'111 111 <br /> Print Name )C4 0-rP ,1�r O Q V Date x•4; , <br /> SE_ESITE SMi4�rp lN,' INiT IV��WQRIPLAN DATED <br /> DEPARTMENT USE ONLY `� <br /> Application Accepted By Date Issued �' a` (1 �1�Area(..f <br /> 1 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# - - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/181L,0 0 <br />