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0 r a <br /> n ((� 1p�f WELL PERMIT APPLICATION FORM UNIT IV <br /> ECE " <br /> W EDSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> AUG 3 0 2000 ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") FIDE COPY <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3450 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [plication is hereby made to San Joaquin County for apermit to construct and/or install the work described. This application is made in compliance with <br /> in Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> /QFNJAn.w. fru-7 QZ 60r <br /> &A0 SL Location Gr drvx4 Cross Street 4CRY /T45bn/ <br /> ✓ —`-7 <br /> Assessors <br /> Zip ) Parce[# <br /> 20PERTY Owner fTAa✓.✓ Address/O.4TIM /6/0 CtYE;�! rrw Zip SZo phone# Zof Y68 36av <br /> 57 Contractor� < ,f �"iu-I • 65}- <br /> 72_�.Lart -, ___Address No,...tr City MAti//TN( Zip 'ICS- Lic#Yft"/6!'phone# 92S'-Y/3-$'Fxt� <br /> msultant I Sub Contractor L"S �F✓/N$ �q rc Address/960 /'~I;--rr /ZT0/-r-Cft n. ✓446 �_ <br /> Y Lic# iv Phonek5/d 65y y!-OD <br /> S Coordinates:X ,Y ,Township Range Section <br /> JRK TO BE PERFORMED <br /> JEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) nESTRUCTION(choose type below) <br /> 0 SOIL BORING# ((__'' <br /> 0 WELL VER-BORE <br /> # <br /> Cher: 0 PRESSURE GROUT <br /> )MMENTS: St/ —013 urr�®f dvFE02c[fp c.� /2�- Orq ry J,o p <br /> PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS 6/6ots FO To Ju/1FacE' <br /> AONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERSOHOS_c <br /> JR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> :OIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> )THER: CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> !reby 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 /> i Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> which this permif is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION laws of Califomia." Contractors hiring or sub- <br /> tracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued /shall employ persons subject to <br /> mRKMAN'S COMPENSATION Laws of Califomia." <br /> ��1 <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ted x -/. 7 (aa�/ 'C'sn'2 Title 14";er r0 .✓�"may--r+ate�/z/w <br /> EE SITE MAP N UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY ` <br /> plication Accepted By 0 .00 <br /> ut Inspection By ,� Oate Issued Area <br /> Date -?� Final Inspection By Date <br /> truction Inspection By 'C� Date ' <br /> MMENTS I CONDITIONS: <br /> :COUNTING ONLY: AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ov YJD 60' 32-42— L3 v <br /> -T IV- 5/99/MI <br />