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69/25/2082 13 16 2094683433 FIFTH FLOOR PAGE 02 <br /> a <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EI-113") <br /> 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br />' NON-REFUNDABLE PERMIT EXPIRES? 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 Environmental Haalth Division <br />&ELL location 5000 S. A WORT WAY C,E DIXON{} <br /> Assessors <br /> Gross Street x N 5T city 5Y o t k tD N _zip 9�,2 t?b Parcells <br /> PROPERTY Owner$TOG TON MttRo AIit ORT4ddress SOOO SAIF FOAT !t X City STOGHTOP1 zip 95206 Phone#(W-91460-4-100 <br /> IC57Conlractor MIYCHF_tL UAILLRJ' rAddress 10619 MILA-i'LOWAY _G,tyRAM(;h0 Zrp956'+0L,,16126iJPhonatx 9�6 t32`3S83 <br /> — coRpOvA R,G, <br /> Consultant/Sub Contractor R A M AG-F C IV V Address F 0, 1301 8 6 9 Cily RANC}4 0 Lia#S S G Phone#(91 b 3 5`1'325 0 <br /> MUISII;TA <br /> CS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER, OTHER-) Q DESTRUCTION(choose type below) <br /> �3) 11 SOIL BORING# (1 OVER-BORT: <br /> i WELL tr MW-I M%4--4_ t1W-1 a PRESSURE GROUT <br /> 'Other <br /> OMMENTS <br /> YPE OF WELL. CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA OF BOREHOLE: -IN MULTIPLE CASINGS?(I YES I NO WELL CASING DIA 7'IN <br /> IsRACTION D AIR HAMMER/ORIVEN CASING THICKNESS_SCN!{O TYPE OF CASING Q STEEL J PVC Q OTHER <br /> OR a MUD ROTARY DEPTH OF GROUT SEAL_, 4 -V TT- TREMIE TYPE TO eE USED EJAUGERS &HOSE <br /> 0 AIR SPARGE I]PUSH POINT GROUT SEAL PUMPED 0 Yes Q No (NOTE.MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING (]HAND AUGER APPROX BORING DEPTH J O-F _T, I BOLTED TRAFFIC BOX or U STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED? Nom-(it YES,list specifications here) <br /> COMMENTS 9 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances Slate Laws and Rules <br /> Mand Regulations of the San Joaquin County Homeowner or licensed agents signature certifies the following "1 earlity that in the performance of the work <br /> for which this pormrt is issued,r shall not employ parsons subject to WORKMAN'S COMPENSATION Laws of Callfornla" Contractor's hiring or sutr <br /> contracting signsiure certifies the following 'I certify that in the perWMarce of the work for which th,s permrf is issued r shall employ persons sublecl to <br /> WORKMAN S COMPENSA TION Laws of California <br /> HE AgIPLICANT HRS IN ADVANCE FOR A7ei <br /> EOUIRED INSPECCT�IO S �sf <br /> Signed x <br /> Title <br /> r+ Date 6 S v Z, <br />'SEE SITE MAP IN UNIT WORK PLAN DATED 915191 <br /> DEPARTMENT USE ONLY <br /> Date Issued 9Z Area__. <br /> pplication Accepted By (%� !SC.9e==:: ------� pales- <br /> rout inspection By Date Fintio <br /> al Inspecn E'Jy <br /> esiruction Inspection By Date <br /> COMMENTS r CONDITIONS <br /> FAC# <br /> UNTING ONLY AICW <br /> pE CODES FEE INFO AMOUNT REMITTED CHECKNA' RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3 _C) <br /> o j .��.0D a�R <br /> 003f3Z <br /> 1JNJT TV-6/1/99/sign bkpg/MI <br />