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HERMIT APPLICATION UNIT IV <br /> . WELL FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-344c. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE8,R.FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install t ie work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaq jin County Public Health Services, Environmental Health Division. <br /> _ Assessor's <br /> WELL Location �_I C k • Wt I Vo.t'.V-t y L Cross Street Nlq 4���� �U City Md� ��C a Zip Parcel# <br /> PROPERTY Owner_L i I c{ NO 0-t C c� _Address OU W C r Z City I`4d 4 c i Zip 4 5 36Phone#g�� -� 05 <br /> C-57 Contractor A4vaur•d 6 F14NirCrWAddress 11005 N v'Jfe.4 _LLu�City 5TKvi Zip45JQ Lic#6gt7�2'TPhone# 'fiY- 1006 <br /> Consultant I Sub Contfactor 4d 4 Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER" 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# }? I - 0 OVER-BORE <br /> 0 WELL# a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: 5 W; javuv" 7Oc) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEMULTIPLE CASINGS?0 YES n NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE -,PUSH POINT GROUT SEAL PUMPED: 0 Yes DNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') j <br /> )LSOIL BORING 0 HAND AUGER APPROX. BORING DEPTH d 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPO ED? VIA ( if YES, list specifications here): <br /> rot r MID <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 witl 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 employ persons subject to WORKERS'C MPENSA TION Laws of California." Contractor's hiring or Sub- <br /> -contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL-THE UNITIV INSPECTOR 48 WORKING HRS IN,AD ANCE.FORALL REQUIRED.INSPECTIONS. <br /> Signed �'� Title/Company.�_-L i4T G za V1NG'�v1 WiL4 <br /> Prins Name4 u<i c Iti V-e Date q/00 <br /> SEESITE MAP... IN UNiTylVWQ2iPLAN DATED .X31:. ,a.�a ;° �e���= <br /> DEPARTMENT USE O 4LY <br /> Application Accepted By Date Issued i �U Area <br /> Grout Inspection By_4�C-N Date 75(-Z-0100 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3sol oC) 00aal5g <br /> 1/18/2000 <br />