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WEL,,. PERMIT APPLICATION F .:1M 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) 468-3449 <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 wit*.-, <br /> San Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> f� ,� II / // Sl,o re Ir n 2 Assessor's 09! a O <br /> WELL Location 3 / Wt?_S i #'CIMAltr L-t+rle Cross Street Dr`%Ve City Sfoc-k,I On Zip95- aI t1 Parcel"_ /ZI <br /> FL <br /> PROPERTYOwnec�-cwr�,'TPrJnr,I �-�- k/ P-SO Address1�71 l�I�,�c� �-Vg 8W. Citylr�.P-I�,Ee-,� Zip 33401 Phone: o Q-331 <br /> C-57 ContractorSn .✓.r L��Ier,h,,,i�hc, Addressci5 Wi1w�� �_nrf_ City15��4,y Zip�5ab Lic#Slaa6KPhoneRIa��y`S-g�� <br /> onsultant ct F10-��i1 E„vi dnPital r+IAddress/YQ0 Frov,dem[, li%jhW"LCuyNof-uaod Lic# Phone#(7B)))y-Cm) <br /> rrl <br /> GIS Coordinates;X Y Township — Range — Section <br /> WORK TO BE PERFORMED <br /> o NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 17 DESTRUCTION(choose type beloyr) <br /> Q SOIL BORING# 0 OVER-BORE <br /> / 11 WELL# e 0 PRESSURE GROUT <br /> -Other: D�;t1 r;� Lfh0)low Sf-2),, c cora� / 1 <br /> COMMENTS: r1oni�-0�'n9 t✓e(lS ir,S7` �'<cl 4-o o�0-3a -FQq- _ belou svrAce � cjj; <br /> TYPE:OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> S MONITORING /HOLLOW STEM DIA. OF BOREHOLE $ MULTIPLE CASINGS?o YES I NO WELL CASING DIA: rr <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS.Sck. t'l0 TYPE OF CASING: 0 STEEL 1 PVC 0 OTHER; <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 14 I-a ct TREMIE TYPE TO BE USED: ®AUGERS 0H0Sc <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes A No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 1544- (�d .x) a BOLTED TRAFFIC BOX or 0 STOvE PIPE <br /> 0 OTHER;_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE RORINGS-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 R+jli. <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 wore <br /> for which this permit is Issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California," Contractor's hiring or sub- <br /> contracting signature certifies the following: -I certify that in the performance o£the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSAT10N Laws of Califomia. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed X ��/I 2 Title/Company VF d�cchhic� ! ��I✓ills / �'��a+n,�nylr�h�� i.l �)r"r✓:�_l I.r <br /> Print NameBe•-,so-. �. l7aviC1 Date <br /> SEE-,SITE MA_ P .IN .UNIT IV WORK PLAN D T_ ED_: <br /> •-....A ..... <br /> DEPARTMENT USE ONLY <br /> c <br /> Application Accepted By Date Issued f Area ` 7 <br /> Grout Inspection By Date 1 d 0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,a-P 522' T% 66 S 0 0 2-35 ? <br /> iitsiz000 <br />