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WELL PERMIT APPLICATION FvRM UNIT IV <br /> SAID} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .kpplication 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 nmentals <br /> Health Division. <br /> HELL Location �ips Street////• XF �tj <br /> � ity Zip ParceI# <br /> C / <br /> PROPERTY Owner dress r�� �'YaICNy' ity / c ZipPhone#�37-A90 Sj <br /> 57 Contractor A//ddress GGd/.�+c S�n _ I Cit 'n(l`sd� ZZiof/S�//' Lica ?Z&F6�1one#4�C-777-wo <br /> Consultant Sub Contraaor Jdc. Address O'0IJ�X s7r;r1 g( CiryJt� PhoneZ�j.527•S C4S4 <br /> 31S Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING (CP<EOPROBE YDRnvi iNCH)HAND-AUG=R. OTHER-) 0 DESTRUCTION (choose type below) <br /> /�S G p���prorp�, 0 OVER-30RE <br /> 0 WELL= ( (V� 0 PRESSURE GROUT <br /> 'Other: <br /> .OMMENTS. <br /> -(PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> ] MONITORING 0 HOLLOW S i cM DIA. OF BOREHOLE 17-MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA <br /> TYPE OF CASING. ST`c PVC OTHER: <br /> ] ;,(TRACTION 0 AIR HAMMER/DRIVEN (%+SING THICKNESS 0 0 0 <br /> ]VAPOR 0 MUD ROTARY DEPTH CF GROIT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0HOS E <br /> 3 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH /(�) 0 BOLTED TRAFFIC BOX or 0 STOVE PIP: <br /> ] OTHER: CONDUCTOR CASING ?ROPOSED') YES. list specifications here). <br /> ^MMENTS e m ��0 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that I nave prepared this application and that the wont will be done in accordance with San Joaquin County Ordinances, State Laws. and Ruies <br /> and 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 /> for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> :ontracting signature certifies the following: 'I ce.niN that in the performance o1 the work for wniUn this permit is issued. ;snall employ persons subject to <br /> NORKMAN'S COMPENSATION Laws of California.' <br /> PLI ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title CihS�c f � Date S—SC O <br /> Signed x <br /> SEE SITE MAP IN NIT IV WORK PLAN. DATED- <br /> DEPARTMENT USE ONLY n� <br /> Date issued Area / �1 <br /> AopliCation Accepted By —� <br /> ;,rout Inspection By <br /> Dare S Final Inspection Date <br /> By �t'L C" �3 C <br /> Oestruction Inspection By Date - <br /> COMMENTS I CONDITIONS: Cf ECIC ,�P,.� �n rm t C C S L <br /> =AC# <br /> I <br /> i ACCOUNT ING ONL". A!D# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY I DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> awl t �GI �cl 3a (o ua�Ic�l SR# d 62 - 15� <br /> UNIT IV- 5/99/MI <br />