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1IV U411bU1 14 4b 2U%J4b13J4.3J r lI I h I-LUUl� r�►ut nL <br /> 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) 468-3450 <br /> NON-REF VNOABLE PERMIT EXPtRcS yEpR FROM DATE ISSUED <br /> Appl,catLoa rS hereby made to San Joaqurn County for a petrr..t to construct andtor instal)Mew ork desci.bed This aapbcst.on is made.n compliance with <br /> San.loaqu.n County Oevelopmeni Ttle Chapter 9-1115 3 and the S12rnd2rd3 of San.Ioaqu.n County Pub-t}C�rteattn Services Envr p�centaHealth Division <br /> L r t ` ff__ p {��, Ct S 1pG� 1OT► Lp, ParceMttA_1' <br /> vvELL LocZkfioO� - <br /> rl.- sWddme, Z� ZiP 5 honed <br /> PROPERTY Owner ��`�-1 Gz +''`` - <br /> (� ` ysi3 �4451�5 Phone g 2,S)3 -S ffQU <br /> C 57 Contractor �Y'I1 ,V\ Address�5©% a y`�` ,,, L C,ty '..M Zip <br /> ']_�Q �C3�\►1tS S C,tySO"h-.N L.td PhoneKt7D7 <br /> Consultant!SuG Contractor-�1M7�r�o� w+Fbk` � Adaress <br /> GIS Coofdrn3tes ?( <br /> Y TCWnshrp Range Section. -- <br /> WCRIC 70 H1r pERFOR)VIE17 <br /> Q(NEVt!WELL I BORING (CPT GEOPROGE HYOF2OPUNCH HAND-AUGER OTHER') Q DESTRUCTION(choose type oelow) <br /> Q <br /> a SOIL BOQ PRESSURE <br /> RING A OVER-BORE <br /> �NELL# Gr"tOtJT <br /> -Other <br /> C'�MEN7S <br /> C--M ENTS L CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS �+ <br /> dbq I70RlNG g'�IOLLOW SSM DIA.OF BOREHOLE, ' • MULTIPLE CASINGS-'fl YES i�0 VVELL CASING DIA 2 <br /> RAcnoN Q AIR HAMMERIDRIVEN CASING T)tIClwEssSc�+�40 TYPE OF C.151eVC 0 STEEL EVCp/A OTHER <br /> rj VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL* n TREMIS TYPE TO BE UScO Q�tlGERS QHOSE <br /> a AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED Vers {1 No (NOTE. MAXIMUM FREE-FALL DEPTH IS 301 <br /> SOl[ gORtNG a HAND AUGER APPROk BORING OEPTH%— OOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROP05ED7 N O L+r YES ltSt 5pecsfiCdt+orss here)GTH> R <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I ncrc)y certify Chet I have prepared this appllcar,on and that the work w.0 Cr"done,n accofdance wrtn San Joaquin County Ord.nanr_s State Laws and Rules <br /> and Regulations of the San Joaquin County. Hornecwner or licensed agent S Sr4naturt certifies the following. -I corury,that,n d+o performance of the work <br /> for which rh.5 permit.s issued,I Shaft not ernptoy persons subject to WORKMAN S COMPENSATION Lao's of C9hfom»` Corrttracior s hinny or sub- <br /> for <br /> signature cer'.G9s tfte followulq- ')CerdfY that in thea P0rfcfM0 of rho work for which ibis pamt,f,s issued !shad omploy persons suDlect to <br /> wopKmAN S COMPENSATION Laws of C61rfOmla <br /> THE (CANT MUST CALL4$HRS IN ADVANCE FOR ALL REQUIRED INSPSCTIONS <br /> 1 Z �8 O <br /> Signed z <br /> T'rtl /'OTl19/lr!!l��e <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> A potrcac,on Accepted By t 1,> n,- Da„T.«..an <br /> Groat Inspection By <br /> Oate Feral tnspevion BY Date_, <br /> 7e5tructlon Inspection By Date <br /> COMMENTS I COND)TIONS <br /> FAC2 <br /> GOUtv'1'ING ONLY. AIDR <br /> PE CODES FEE INFO AMOUNT REMI--TED CNECXVJCASH RECEIVED BY DATE PERMIT/SERVICE REQUESTNUIVIt3ER )NVOfCE <br /> 3 sc <br />