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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> cation is nereoy made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> Location �Igo`I E• (ti�ypDc�'Ak'U A VC• Cross Street 11tyrAT City k(rcKrt-76 Zip 5J Parcel#24 3-tm-C'7 / I <br /> PERTY Owner f r�tr' �'�( �Addrre s '7`�iJ'S4 I VL- S city LOD t Zip Z 0 P�h�o/ne# 14q 33 j.'I qI�-7 <br /> Contracior 4 4 U) 7)£)U W6- /^rC Address %' y , Sc`x' S� City"/ V151� Zip Liptil- q (PKone# IU f —3q4--2 Js <br /> )- � V C� �gHU43m Luh 1, Phone#2cc1 5 f{i oZry 3 <br /> suttant 1 Sub Contractor 6x I�r1/15C I%J� Address'Z`1 7 .ltCt►YuMJ City _ <br /> �oorctinates: X Y Township Se"�'7I� Range 7 QST Section /C <br /> RK TO BE PERFORMED <br /> W WELL/ BORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') XDESTRUCTION (choose type below) <br /> 0 SOIL BORING%. 0 OVER-BORE <br /> 0 WELL# -X'PRESSURE GROUT <br /> MENTS: <br /> OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS It <br /> DIA_OF BOREHOLE MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: <br /> JNITORING )<HOLLOW STEM 2 <br /> i*TION 0 AIR HAMMER/DRIVEN CASING THICKNESS Z TYPE OF CASING: 0 STEEL %PVC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL G'3 TREMIE TYPE TO BE USED: 0 AUGERS OHOS_ <br /> R SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes J,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> :IL BORING 0 HAND AUGER APPROX. BORING DEPTH 1.c' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'HER: CONDUCTOR CASING PROPOSED? A/A (if YES, list spec i�cations nere): <br /> iMENTS: fi L! tTG[c f � t(C✓ ` GHE-1W A rl C <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS) <br /> reoy certify that I have prepared this application and that the wont will be done in accordance with San Joaquin County Ordinances, State Laws, and Ruies <br /> 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 /> vnicn this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> :racting signature certifies the following: 'I certify that in the pertomtance of the work for wnkn this permit is issued. I snail employ persons subject to <br /> RKMAN'S COMPENSATION Laws of Ca/ifomia.' <br /> THE APPLICANT MUST CALL 48 RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i e c x Title <br /> -E SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> kation Accepted By Date Issued Area <br /> iL Inspection By Date Final Inspection By Date <br /> .ruction Inspection By Date <br /> 1MENTS/CONDITIONS: <br /> 4TING ONLY: AlD# FACS <br /> CODES I FEE INFO AMOUNT REMITTED CHECK#iCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> =V - 5/99 /M: <br />