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WELL 'ERMIT APPLICATION F�:M <br /> UNIT IV <br /> SAN JOAQUIN NOAL HEALTH DIVISIONNTY PUBLIC HEALTH SERVICES <br /> (PH EHD) - <br /> ENVIRONME <br /> ,•M <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED application is made in comcliance:v,;• <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install thin work described. This app Assessor's <br /> San Joaquin County Development Title, Chapter 9-1115.3.and the Standards of San Joaquin County Public Health Z er 5 7Environmental or s Health 'I L� <br /> C� Cross Street t'a City Mi?7rV_ p---- <br /> WELL Location �js�'Phonem S�'�' <br /> Ss n���Jc;4th%� Address` t 3 __���66 3 Me_City lefoyt'3Tv, ZiP� <br /> PROPERTY Ovmer�—T---T 9 <br /> �Zi � <br /> C-57 Contractor� ""'cx Address 9S�%S t�.� <br /> tte 6C!, <br /> Co Cir /L� P ?� Lic7 5'd Phone?Y00 zC i-cy2i e <br /> Address <br /> C ity_____Lic._P h o n e? <br /> Consultant SubContractor Ran a Section <br /> GIS Coordinates.X <br /> Y Township %'y g <br /> WORK TO BE PERFORMED Q DESTRUCTION (choose tyPe be`.o`J <br /> HYDROPUNCH,HAND-AUGER,OTHER-) Q OVER-BORE <br /> O'NEW WELL I BORING(CPTaGSOIL <br /> BOR NGING# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> TYPE_ O c � 'l ' MULTIPLE CASINGS?etS K NO WELL CASING D!A:Z.c�f <br /> MONITORING <br /> OLLOW STEM DIA. OF BOREHOLE �- STEEL Q OTHER: <br /> Q EXTRACTION Q AIR HAMMER/ CASING THICKNESS ,Sc-c , _TYPE OF CASING Q <br /> DEPTH OF GROUT SEAL-54,t C z6-0 TREMIE TYPE TO BE USED: Q AUGERS OSE <br /> Q VAPOR GROUT SEAL PUMPED: Q Yes , WNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q MUD ROTARY <br /> Q AIR SPARGE Q PUSH POINT e �BOLTEO TRAFFIC BOX or Q STOVE PIPE <br /> HAND AUGER APPROX. BORING DEPTH ZS S�• G G��tcEs <br /> Q SOIL BORING Q f YES, list specifications her.) ' fi <br /> Q OTHER CONDUCTOR CASING PROPOSED yam-( Z� f ko� /4 G pry <br /> Q OTHER: c <br /> tt o 2 <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESSd0R ENCROACHMENTtnt Ordinances, <br /> Laws, <br /> and Rules <br /> Joaquin 0 <br /> 1 hereby certify that I have prepared this application and that the work agent's <br /> be doge in a g Y performance <br /> ssued, I shall employ persons subject to <br /> hall not employ persons subject to WORKERS'COMPENSA71ON Laws of California." Contractor's hiring or sub- <br /> and Regulations of the San Joaquin SCounty. Homeowner or licensed a ent's si nature certifies the following: 1 certify that in the <br /> for which this permit is issued, I <br /> ermit <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this R ALLis/REQUIRED INSPECTIONS. <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV I SPE�OR 48 WORKING HRS IN ADVANCE F � ems+ <br /> Title/Company <br /> Signed x – Date �Z ee <br /> Print NameP <br /> SEE-SITE_ MAP-IN UNIT IV WORK LAN DATED:- <br /> DEPARTMENT USE ONLY �l <br /> Oate Issued // Z p rea_�--- <br /> Application Accepted By Date��– <br /> Date Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> t ' <br /> COMM TS I CO ITIONS: <br /> ACCO NTING ONLY: AID: <br /> RECD BY DATE <br /> PERMIT I SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#� ti2 �� <br /> (� 0 () B � 1/18/2000 <br />