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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 FILE <br /> C <br /> (209) 468-3449 <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 /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> NELL Location 3t J �C.FP6(41`�'`�T S I' Cross Street ,�A-c��� City SQL�0 Zip f�-�s Parcel# /4.3 -2 Z -/4- <br /> ?ROPERTY Owner l�- � �f'�yJI�010 Address /01/ �'�,Piyldwit,� City. sMLkAW Zip 1y1.Os Phone# AS -S6 75 <br /> AdVA✓c-e d JiifL �, 9rXs�1.r ' � � 1 <br /> C-57 Contractor /�PDC,J1!(e01h e )Address t, 9/'/J Wp'l City STC Zip q! �Lic#6602,�7Phone# � 7-7Q�1 fi <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WFtt/BORING(CPT,4 EOPR B HYDROPUNH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> ING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: �'�Cr►�lvh l e �I�O✓1T <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE /,7Sr1 MULTIPLE CASINGS? 0 YES $ANO WELL CASING DIA:IJA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: /1/ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR 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 4 S '�.'�I 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> 0 OTHER 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES. list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby 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 /> and 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 /> for which this permit is issued, l shall not employ persons subject to WORKERS'COMPENSATION Laws of Caiifornia." Contractor's hiring or sub- <br /> contracting 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 /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x /'G (A- C C Title/Company 5mrF Ca©L11dvW, 6dc G=Joj/Az9.�,+.�.0 1��—I' C � <br /> Print Name NQ t A C t(Lk Date <br /> EE SITE MAP IN UNIT IV WORK PLAN DA ED. 0S AC OU <br /> DEPARTMENT USE ONLY ¢ <br /> Application Accepted By Date Issued <br /> U 7^0 0 Area (!J <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> oI D� �'- �� 0023 z <br /> iiisi2000 <br />