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CONTINUE FROM PREUICUS PPGE 001 <br /> RC) <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> EC � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> JUS, 9 9 zoo? 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> F opfp r <br /> N T HEALTH <br /> PFRP, � ��II►��/-+� cc++ NON REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Appl4aton is Flag NiEf N San Joaquin County for a permit to construct and/or install the work desenbed This application Is made in compliance with <br /> San Joaquin County Development Tale Chapter 9-11 i5 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> V <br /> ! / Assessor's <br /> WELL Location � Y .00.0 � Cross Street IC1+q-,Fri ,City r col 2 pg5Z C31 Parcel#o,�M-04Q Z <br /> PROPERTYOwnai;SkkA <�er.t,r ..,ol. <br /> C-97 Contractor Ctictye. City n�q e> 21p4sg� Phonate_ -<C-C>-<C-C>Consultant/Sub Contractor js tro.�(ddress 74QL4 0 <br /> Cit o Lica�Z4 Pnone# <br /> GIS Coordinates X Y Township Range Secton <br /> WORK TO BE PERFORMED <br /> '�NEVV WELL/BORING(CPT GEOPROSE HYDROPUNCH HADD ALIGER OTHER-) D DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER BORE <br /> SWELL# 0 PRESSURE GROUT <br /> 01her — <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1r <br /> [MONITORING HOLLOW STEM DIA OF BOREHOLE N 1z MULTIPLE CASINGS?DYES ` NO WELL CASING DIA'Y r! <br /> /D EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING O STEEL IVC Q OTrtER <br /> O VAPOR 0 MUD ROTARY CEPTH OF GROUT SER f TREMIE TYPE TO SE USED GAUGERS POSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED O Yes D No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER APPROX BORING 0EP7`H OLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER O OTHEP CONDUCTOR CASING PROPOSED-_^A> (If YES list spcGf#eatlens here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and tt�at the work will be done#n accordance with San Joaquin County Ordinances, Slate Laws and Rules <br /> and Ragulaihon:of the San Joaquin County Homcawncr cr licensed agent's si9naturc crrtifcs the following I ceR,fy that in the performance afthe work <br /> for which Mrs permlr Is Issued l shall not employ persons subject lo WORKERS COMPENSATION taws ofCahfoMia' Contractor's hiring or:ub <br /> contracting signature certifies the following 'l certify that In the porfbrmance of the work for which this permit is issued t shall employ persons subject to <br /> WORKERS CO MPENSATION Laws of Cahfomfe <br /> CALL T1I6 UNIT IV INSPECTOR 48 WORMING HRS IN ADVANCE FOR A-LL REQUIRED INSPECTIONS <br /> Slgrcd x � �' TstlelCompany zs:/ t- �, <g,-. i" <br /> Ar <br /> Print Name _ A *f Date O� <br /> I—M <br /> PARTMENT USE ONLY <br /> Application Accepted By �. Date Issued 3 t7d Z Ares_ <br /> out Inspection sy Dat Final Inspaction By 44 Date <br /> estruction Inspection By Date <br /> COMMENTS l CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK 0REC D VYDATE PERMIT I SERVICE REQUEST# INVOICE <br /> i <br />