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WELL PERMIT APPLICATION FORM UNIT IV <br /> \ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> . 304 C J Weber Third Floor, Stockton, CA , 95202 <br /> " (209) 468-3449 <br /> Applica[ton.s hereb m NON-REFUNDABLIr PERMIT EXPIRES 1 YEAR FROM Ii ISSUED <br /> Y ace[o San Joa4U+n County for a permit to construct ani'/nr r ll the worx Described This aPal+cation is made in carnotliancc x+th <br /> San Joaquin County Development Tate Chapter 9 11 15 3 and the Stanoaras of San Joaquin County Public Health Services Environmental Heamh Division <br /> B 004 1q li <br /> 4411k1_Location (,i7zbf,ZCrass Street r jve Csty 7?,r/C Zip��� V Assessor s <br /> �ParCelflr7 -o 3 7 <br /> PROPERTY Owner 1!'ILFL/?.vYrN' � <br /> Address d 3ZG C,r ZiAi�hone#�Ji'GZ �7G7 <br /> C-57 Contractor r, ��rN� ddress G� /6 r <br /> CIt* ZIP Li0X.Z6L o�rPhonitic 77'f'/d^a <br /> Consultant/sem, (� AdCrEssy g.►)r yy�t,h Ci ,,�y� <br /> GIS Coordinates X f_ 7 Y ,j-3rr } 0 O Township---1 _N Range G AF Section d <br /> waRr< ro a�PkltForMr�O <br /> — ------ ---- <br /> I /BORING(CPT GEOPRoBE HYDROPUNCH HAND-AUGER OTHER,) <br /> SOIL BORING C Q DESTRUCTION(choose type below) <br /> Othar Q ELL 0 0 OVER 90RE <br /> COMMENTS <br /> [j PRESSURE GROUT <br /> TYPE----OFWELL INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING gHOLLOW STEM <br /> 0 EXTRACTION DIA OF BOREHOLE,MULTIPLE CASINGS°p YES rC) WELL CASING DIA <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING (]STEEL Q PVC Q O'f HER <br /> oe <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL w <br /> Q AIR SPARGEp 'REMIE 7Yve TO BE USED (]AUGERS pHOSE <br /> q USH POINT GROUT SEAL PUMPED a Yes 0 No (NOTE, MAXIMUM FRErm-FALL. DEPTH IS 301) <br /> SOIL BORING Q HAND AUGER APPROX BORING DEPTH <br /> 0 OTHER Q OTHERQ 80i TRAFFIC BOX or Q STOVE PIPE <br /> COIuDUCTOR CASING PROPOSED I if YES III SPeC-fications her!) <br /> MENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cert!!)that 7 hilus prepared this aeplicauon and tAai the work will be Cane in accordan <br /> and Regulations of the San Jnagtrin CountyNorn ce wnh San Jo9ouin t-aunty Ordinances State Laws and Rules <br /> eowner or licensed agent s signature certifies rhe`pllawing 'l cer�lfy that in the performance Of the work <br /> /or which this nature is issued f shall not employ persons subjell ro WORKERS COMPf NSA TION;aws of Ca!!/omra" Contractors hmnq or sub. <br /> contracunq e,gnature cerhfles the fallowing t cerrrfy Ina,rn rhe <br /> *ORKIERS'COMPI TION Laws of Carrtomta ped°rmarrce or me work for whrcq rnrs,oarmrl is issued I snal/employ persons sualect to <br /> r- APP <br /> L NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIOiy$ <br /> Signed /J A/ L <br /> Title �„ItyS•ty�'�it�/j Data / <br /> SEE SIN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> tppllraUon Accepted By ��� � Lr <br /> Trout In6pection Ey Date Issued Area f _�_ <br /> Iestrvaion rnspectfon By gate Final inspeictlon By pate <br /> Date <br /> OMMENTS CONDITIONS CQ.vri?.r` 11,14.!,11 e-411 <br /> !s1 .�n e IY1 ►�. E.f b C t Q, <br /> I <br /> ACCOUNTING ONLY AID* FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK+t/CA5H RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> RA <br /> C 57 LICENSED CONTRACTOR MUST SIGN LICENSE SCWORKERS' COMPENSATION <br /> DEGLr�RP►TION <br /> NIT rV 6/23/99/Sign bkpg/MI <br /> 0 1 <br />