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• <br /> IV <br /> WELL PERMIT APPLICATION FORM <br /> UNIT N <br /> SAN .IOAQUIN COUNTY PUBLIC HEALTH <br /> ktSERVICES <br /> EHD 17) <br /> ENVIRONMENTAL HEALTH toc0N <br /> 304 E. Weber, Third Floor 468-3450on, CA., 95202 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 /> Assessors 464'18 <br /> 9�� S�CkC On DP Parcel# <br /> San Joaquin County Development Title,Chapter y for 3.3 and the StandaQrdsyof.�S�a�n J�oapquin County Public Health Services. Environmental Health Division. <br /> L 6) K Cross Street P�City-��r S 1 6 33 <br /> WELL LocatI tic 0.0 —II - tpr,�ZiF 52.0 -phone#� <br /> ddress nOa� 4451 ./0.25 3l3-SgQO <br /> PROPERTY Ownei_ cl y- �h(2 TJP 4s53 Licit Phone <br /> 61r.V °(SU Gih (dol q3`�-`t8s( <br /> hQ Address— <br /> C.57 . Licit phone <br /> C-57 Contractor d ,t '):70 p�ty"`$ S City <br /> (_,� s�� ppptyQ1,1A� Atldress <br /> Consultant/Sub Contractor__ Ranges�Section� <br /> Y <br /> Township----- <br /> G15 Coordinates:X_�= <br /> WORK TO SE PERFORMED 0 DESTRUCTION(choose type below) <br /> �OVER-BORE <br /> NEW WELL!BORING(CP7a SEOtL BCOR NG#DROPUNCH.HAND-AUGER.OTHER') 0 PRESSURE GROUT <br /> WELL# <br /> 'Ocher: / 2" <br /> CC;.IAMENYS: G✓ WELL CASING DIA: <br /> 7YPE_ O� CONS7RV TYPE CONSTRUCTION SPECIFICATIONS MULTIPLE CASINGS? YES NO✓ <br /> HOLLOW STEM DIA.OF BOREHOLE O STEEL e O OTHER: <br /> I�MONITORING H� TYPE OF CASING: O HOSE <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS��^'�4 <br /> DEPTH OF GROUT SEAL* t TREMIE TYPE TO USED: &AUGERS f] <br /> U VAPOR a MUD ROTARY es Np NOTE= MAXIMUM FREE-FALL DEPTH lS 30') <br /> PUSH POINT GROUT SEAL PUMPED: t3R 0 t I �OLTED TRAFFIC BOX or [I STOVE PIPE <br /> G AIR SOIL <br /> a APPROX. BORING DEPTH e'er <br /> p SOIL BORING 0 HANG AUGER No (if YES,list specifications hereY�--- <br /> CONDUCTOft CASING PROPOSED? <br /> OTHER: <br /> COMMENTS: <br /> R ENCROACHMENT PERMITS. <br /> NOTE: OFFSITEBORINGS REQUIRE ACCESS OR um Co that in the Pefo^r ante of the work <br /> I hereby certify Ihet I Rave prepared this app <br /> tication and that the work will be donge in accordance with San J9aqufn County Ordinances.State Laws, and woek <br /> Persons sub'ect to WORKMAN'S COMPENSATION Laws of Call/omia." Contractor's hiring or sub- <br /> and Regulations of the San Joaquin County. Homeowner or licensed ageni s si nature certifies the followin <br /> to <br /> for which this permit is issued,f shall not employ p <br /> fo which <br /> signature certifies the following: "l employ <br /> that in the perject to a O the work for wMch this permit is issued. I shell employ persons subject <br /> certify <br /> WORKMAN'S COMPENSATION Laws of GANi M � <br /> (CCANTT M , <br /> 7HE ' CALL68 HRS IN ADVANCE FOR ALL REQUIRED(INSPECTION <br /> TtUd�r e <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORM PLANSE <br /> LYDATED / <br /> '�/,� C� Area <br /> f i r Date Issued l r Date rS 20 <br /> Application Accepted By 1 Oate z Final Inspection By <br /> Grout Inspection BY Date <br /> Destrualon Inspection B - <br /> COMMENTS f CONDITIONS: <br /> FACS <br /> ACCOUNTING ONLY: <br /> A10# <br /> CHET#!?ASH RECEIVED BY i DAT O/ PERMITISERVICo�ES REQUEST NUMBER INV <br /> PE CODES FEE INFO AMOUNT REMITTED <br />