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WELL PERMIT APPLICATION FORM UNIT IV <br />SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD" ). <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 l <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR =ROM OA i s ISSUED ORIGINAL <br />Aoptication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in comoliance with <br />San Joaquin County Development i idle. Cnapter 9-1115.3 and the Stanaards of San Joaquin County Public Health Services. cnvironmental Health Division. <br />/ J Assessor's <br />(��t" Cross Street city City ft'C[_ jzL� Zip c , 2C Parcel# <br />WEI L Location re <br />I I ..�t' y- :Address S, �3t1 City FVC p 5 73 Phone# -2 -C L <br />PROPERTY Owner l� I tGc a t�. t <br />5-57 Contractor �' Lt� Address si City li?fcl 11,5FZtZ;pc-jf5 LiCt�z=Y`"�Phone#g�"1T7�4`!Ci'7 <br />/ &K 5�z: C -z,CK Tel- Lic# �Y�') Phone#?�"! <br />Sonsultant !Sub Contractor �/� u t Address �t5' <br />31S Coordinates: X <br />- Y <br />_J Township Range Section <br />WORK TO BE PERFORMED <br />v <br />0 <br />VEW WELL .'BORING ( CPT. GEOPROSE. HYOROPUNCH, HAND -AUGER, OTHER") Q DES RUCTION (choose type below) <br />G SOIL BORING : <br />Q OVER -BORE <br />0 PRESSURE GRCUT <br />,g WELL' n <br />'Other: <br />COMMENTS: <br />-''PE OF 'NEL_ <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICA710NS <br />!ACNITGRING <br />HOLLOW S i cM <br />DIA OF BCRE�tOt_ r " MULT 1Pi2 CASINGS? o YES �,NO WE,1 CASING DIA: '' <br />=X RAC`1ON <br />AIR riAMMER/DRNEN <br />CASING HICKNESS [ YC 'YPE OF CASING: Q STEEL P.�PVC �] OTHER: <br />\ <br />Q VAPOR <br />I] MUD ROTARY <br />DEPTH OF GROUT SEAL /)-' -,REMIE ^(PE TC 3E USED: AUGERS ]HOSE <br />AIR SPARGE <br />p PUSH ?OINT <br />GROUT SEAL PUMPED: a Yes $ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'11 <br />Q SOIL BORING <br />Q HAND AUGER <br />APPROX. 30RING OE.P H ig(�OL 1=0 RAF;:IC BOX or 0 STOVE PIP_ <br />v <br />OTHER: <br />CONDUCTOR CASING PROPOS-0-7 ' (il''YES. ;ist specifications Here): <br />COMMENTS: <br />NOTE: <br />OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br />nereoy certify that I nave prepared this arivicauon ano inat :ne worK will be cone in accordance with San Joaquin -ounty �jruinanuub. aWma . _., o.... <br />and Regulations of the San Joaquin County. Homeowner or !icensec agent's signature certifies the following: "I certify that in the performance of rhe work <br />for wnicn this permit is issued, 1 snail not employ persons Sup/ect to WORKMAN'S COMPENSATION Laws of Califomia-" Contractor's hiring or suo- <br />t aC.i^g <br />signature certifies the following: "t certify that in the performance at Me work for wnt= tltfs permit is issued. f snail employ persons suDlect to <br />NORKMAN'S COMPENSATION Laws of Califomia-' ` <br />THE APPPU ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />�% If"rtiL� <br />i file c,�, .(i�Lc l'� Date <br />�- <br />Signed x , <br />SE_ <br />SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY 6- / i / / F <br />>pplication Accepted By (Z�_ <br />Date Issued `I/ o C)Area � iP u <br />Grout Inspection By Date Final Inspection By Date <br />Destruction insoection By Date <br />COMMENTS /CONDITIONS: W <br />ACCOUNTING ONLY: I AID# I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY OA. cc ?E tf T N MQER I INVOICE <br />UNrT rV - 5/99 /Mr <br />