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WELL PERMIT APPLICATION FORM UNIT iv <br /> ,p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Cp` 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 application is made in compliance with <br /> pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app Assessor's <br /> pan Joaquin County Develo itle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> / Z Cross Street C-�–TL City J i�l Zip Parcel", <br /> NELL L/cati n ri S/ r Grw-x <br /> )-90 Phone" 7a; / <br /> PROPERTY OwnerGvS%5��� Address 6N F L/Ly <br /> l Y T <br /> .!/_ ,/'1 •/!/.�rQ A � CSI z---?q L ] Phone# <br /> ddress3C �2 � C Lic# 0 <br /> NO( , <br /> 1r/C <br /> 3 � �S-G •2.L�b'� <br /> 3-57 Cbntracto� xtGxlgj� Phone S c <br /> lqs E Address/9q,1 S _ /_—fG City /l�V, S Lic. f <br /> Consultant/Sub Contractor I, Section 3 <br /> ,Y <br /> ,Township 4� Range <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED 0 DESTRUCTION (choose type bela:r) <br /> PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER0 OVER-BORE <br /> �IEW WELLS/BORING(C ) � PRESSURE GROUT <br /> SOIL BORING# <br /> 0WELL# <br /> 'Other: <br /> COMMENTS: <br /> u2ffs <br /> CONSTRUCTION SPECIFICATIO G DIA: <br /> TYPE OF WELL INSTALLATION TYPE MULTIPLE CASINGS? YES [I,P�O WELL CASIN <br /> OONITORING [ {OLLOW STEM DIA. OF BOREHOLE�tL STEEL `�'p( <br /> TRACTkON Q AIR HAMMER/DRIVEN CASING THICKNESS ��ff v TS,YPE OF CASING: <br /> TYPE�TO BE USED: 0 A�UGGERSR VOSE <br /> 0 EX DEPTH OF GROUT SEAL�- <br /> 0 VAPOR 0 MUD ROTARY es No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: <br /> cBOLTED TRAFFIC BOX or �TOVE PIPE <br /> p SOIL BORING p HAND AUGER APPROX.BORING DEPTH 30 ' if YES, list specifications here): <br /> 0 OTHER:�— <br /> p OTHER CONDUCTOR CASING PROPOSED. <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESSOR ENCROACHMENT ROACHMENJ in County oTdlIPERMIT S ws,and <br /> the Rule <br /> n oaq <br /> I hereby certify that I have prepared this application and that the work will be do g. , Y p <br /> work <br /> arsons subject to WORKERS'COMPENSATION Laws of California." Contractor's rsons subjecf,to b <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the followin I cerci( that in the performance <br /> for which this permit is issued,1 shall not employpersons j;' <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ p <br /> WORKERS'COMPENSATION Laws of California." <br /> CA THE UNIT IV I ECTOR 48 WO lNG HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company <br /> Signed)' <br /> /� Date <br /> Print Name <br /> S E SITE MAP IN UNIT IV.WORK PLAN DATED <br /> " DEPARTMENT USE ONLY Area�U�� <br /> Date Issued !�� OU <br /> Application Accepted By Z6OD Final Inspection By Date_ <br /> y � _Date <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: - <br /> ACCOUNTING ONLY: AID# . <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �,o r r " l— 1/18/2000 <br />