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C <br /> WELL PERMIT A"PP&ATION FO M UNIT IV <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) D�/ <br /> ' Y <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE COPY <br /> (209) 468-3449 i Fj <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,EnvironmentalAssessor's <br /> Health Division. <br /> Ir/ �c �lA L75-330 Parcel#� <br /> ?(� 7 / " s%. Cross Street �� "r 57- City ZiP <br /> WELL Location T .N� <br /> PROPERTY Owner <br /> �`� '"`�f_/�Q Sbij Address 11595'0 SaMr " "/a itt' Zip Phone# SSB-438$ <br /> C-57 Contractor MDijc5 It'Ae ldress 15-?WJ , WAV- City.5AG• Zip% 1­ic#L7Z617 Phone# 20 f <br /> &JV ht/cc <br /> d � }+ "(00 <br /> onsuu- I Sub Contractor,:y,--fjiU Jit^ Ir+-a� Address �6DS/l�•�✓��SLT,��. City ick . Lic# Phone# Mn7- V(o <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED - <br /> c°-WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HER').HAND-AUGER,OT - 0 DESTRUCTION(choose type below) <br /> @�''' I <br /> 0SOILLB# RIN Z /I/y� PRESSURE GROUT <br /> 'Other: <br /> i <br /> COMMENTS: <br /> TYPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE 8'/n#.(nMULTIPLE CASINGS?Q YES t,y'w� WELL CASING DIA: Z � <br /> 0 EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL IS+&,RV45' 0 OTHER' <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL a I brge TREMIE TYPE TO BE USED: V15GERS OHOSE <br /> 0 AIR SPARGE QPUSH POINT GROUT SEAL PUMPED: 0 Yes a,%t6 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑HAND AUGER APPROX. BORING DEPTH 8 �+�LED TRAFFIC BOX or D STOVE PIPE <br /> 0 OTHER: 0 <br /> OTHER CONDUCTOR CASING PROPOSED? /J (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 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: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employpersons subject to WORKERS'COMPENSATION Laws of California." 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 /> SCAALL-L THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> C' <br /> Signed y"i s' -Title/Company <br /> Print Name / I C —Date1 ©7�Z4 It TJ IIATIcr�W�tt <br /> _ z 3w��.ZeO O <br /> EE SIT MAP` IN UNIT K DA ED IV WORPLAN . <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ; <br /> Date Issued V ! D O Area a� <br /> Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By '�, Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO17 AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 <br /> ,-3y8 ? 5 D Z alp 3 <br /> >najz000 <br /> zz-n✓ r4 ✓ GSC <br />