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WELY PERMIT APPLICATION YORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE EE1 fVED <br /> � <br /> ENVIRONMENTAL HEALTH DIVISION PHS-EHD <br /> ) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FEB I 5 ZOOQ <br /> FF �... (209) 468-3449 ENVIRONMENTAL HEALTH <br /> ��jFj e 1 <br /> -NI-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Appl. ado Joaquin unty for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Jo elonmerlt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 6n I Cross Street Wa City c c h Zip ��� Parcel# <br /> PROPERTY Owner al N '4Q("-^n Address q X , 6I r City n Zip Q C1 honeC_0° g32"S�� <br /> C-57 Contractor_ v6e Address City aoh zip 9 Lic#40)7Phoneka�7-Id06 <br /> Consultant/Sub Contractor LEE Address_Y6D57-/l/. (.ulSaNv City_ Atkl2&Lic# Phon 'G� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 'Other 0 WELL# <br /> 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONETORING 0 HOLLOW STEM DIA.OF BOREHOLE.MULTIPLE CASINGS?0 YES "0 WELL CASING DIA:, _ <br /> 0 EXTRACTION 0 AIR KAMMERIDRIVEN CASING THICKNESS ,NA TYPE OF CASING: 0 STEEL O PVC 0 OTHER:. <br /> UVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_EY1'�i re TREMIE TYPE TO BE USED: AUGERS CHOSE <br /> p AIR t1ARGEPUSH POINT. GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_ D OTHER CONDUCTOR CASING PROPOSED? 1/h (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: "t certify that in theperformance of the work <br /> for which this permit is issued,l shall not employ persons subject to WORKERS'COMPENSATION Laws of Callfomia." Contractor's hiring or-sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is issued, l sha#employ persons subject to <br /> MRKERS'COMPENSATION Laws of Celifomia.". <br /> T API?LICANT MUST GALL'48 WCjRKI�VG NRSN APV hNCE FORuALL REQUIRED 1NSPECTIONSr`1 <br /> Signed x le� V <br /> 1. l! OS/S Date oZ � <br /> Tit <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> E1,. / DEPARTMENT USE ONLY <br /> Application Accepted By !� Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS.- <br /> AC <br /> ONDITIONS: <br /> E,COUNWTING ONLY: AIDS FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 01 <br /> AN <br /> C-57 LICENSED'CONTRACTOR MUST SIGN LICENSE&WORKERS'C OMPENSATi�N,D�CLA.AXh <br /> UNIT IV-6/23/94/sign bkpg/MI <br />