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WELL PERMIT APPLICATION FORM 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 /> oplication 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 <br /> an Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> r Assessor's <br /> ELL Location ), 4' - ( G� JtQ niC, Cross Street��o� City � ���TO+I� Zip CI�Parcel# <br /> POPERTY Owner r,ry Za II ,✓O r TV1 Address LOQ C) C-),I�i Vary City S�1k4Vh Zip ?5,2(1 Phone <br /> -57 Contractor_ f -4f; Address 4Co5'-1y, Gutk� ",( City I K r ZipK�KLic# Z Phonek2OO12-6' <br /> onsultant/Sub Contractor E Address�s Z2 b)(L01) (.1'14 City�Lic# Phone ) 7 <br /> IS Coordinates:X Y Township Range Section <br /> ORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> ether. 0 WELL# 0 PRESSURE GROUT <br /> DMMENTS: <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a)' MULTIPLE CASINGS? 0 YES J(NO WELL CASING DIA:AfI <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IVA- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SLy,\�-ifY- TREMIE TYPE TO BE USED: 0 AUGERS 2$10SE <br /> 41R SPARGE :PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 7�0 <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? IVI'r ( if YES, list specifications here): <br /> )MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ereby 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 /> d Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> ntracting 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 /> DPKERS'COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Ined x Title TG hC � �i l5 I Date___ <br /> 3EE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Arplication Accepted By Date Issued Z- 8- O 0 AreaD 7S J� <br /> _ <br /> Clout Inspection By Date Final Inspection By Date <br />;jC§truction Inspection By °��y�J C�� Dale Z�--�� -- �'ti �� -' �,,t <br /> )MMENTS/CONDITIONS: ort" _ C-4 <br /> ACCOUNTING ONLY: AID# <br /> FArtt <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 1 <br /> 817 ;2 C? VWcg> 3 R# d O alb y g <br /> -57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JIT 1V- 6/23/99 /sign bkpg/MI <br />