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WELL PAMIT APPLICATION FO <br /> RP UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES REr'PgOID <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SQL 10 2p�a <br /> (209) 456-3449 <br /> ENVtiRONMF,y�HEpa-TN <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUEDppSER�VICES <br /> Application Is herby made to San Joaquin County for a permit to construct and/or install the work described. This application ispno th�ComPuance with <br /> San Joaquin County Development Title,Chapter 2-1115.3 and the Stand�arr�d/s, an Joaquin County Public Health Sem <br /> Services,Environmental Health Division. <br /> WELL Location LI J &Q%,/ Cross Street ' ' Ire fly & Zip_=Perssessots <br /> PROPERTY Owner ddress 5V P f Re, 51 City 1154 <br /> L Ti& Phone#j-S 3-14) Q <br /> CItZpr7flwU ?/a <br /> AddreLr& <br /> C-37 Contractor <br /> Consultant!Sub Contractor �"dress 1� 0 '?Paan <br /> GIS Coordinates:X ,Y .Townshlp Range_ Settlor <br /> WORK TO BE PERFORMED <br /> ? ft_1N WELL 1 BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> kSO1,LBO RING# 0 OVERBORE <br /> LL# PRESSURE GROUT'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS k r] <br /> 10ONITORINGOLLOW STEM DIA. OF BOREHOLE—f_ MULTIPLE CASINGS?0 YES .21<10WELL CASING DIAelk <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS__ TYPE OF CASING: 0 STEEL��OC BOTHER: v <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAjjEr2@ej— _TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes $'Flo (NOTE: MAXIMUM FREE-FALL DEPTH IS 3 ' <br /> O SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH00 BOLTED TRAFFIC BOX or 0 STOVE PIPE /J( <br /> 0 OTHER: I]OTHER CONDUCTOR.CASING PROPOSED? (If YES-list specifications here): \f J) <br /> COMMENTS: ;• <br /> Ue <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 Sen Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeoymer or licensed agent's signature certifies the following: "I cerdfy 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 cer!rfy that in the performance of the work for which this permit is issued,i shall employ persons subject to <br /> WORKERS'COMPENSA TION Laws of California.' <br /> CALL TH UNIT IV INSPECTOR 48 WORKING HRS IN ADV kNCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company ' <br /> Print Name e <br /> SEE "SITE_MAP�Y_IN„_UNIT; w: ;,lA[Q_RK PLAN. DATEDc a� 1��. _7 <br /> y EPARTMENT USE ONLY- <br /> Application Accepted By/��� A ssued -7—t —vim Area 0 7 <br /> Grout Inspection By Cv-Il.iiar/ Date„--71i V/0o Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS. <br /> ACCOUNTING ONLY: AID# FArd <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 s� g - - Ab17 SL-7 <br /> 1/18/20DO <br />