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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC5S <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3460 <br /> INOIR-REFUNDABLE PERMIT EKPIRES 1 YEAR FROM HATE iSStXED <br /> Ap*6=Gon in hereby mode to San Joaquin County for n gemht to cnnsbUC:veior insta0 the wok described- This appE coon i5 made in Cornpftance with <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of Sari Joaquin County Pubre-Health Services,E wirOrxnentai Health Diviz art. <br /> 315 S. Center Lafayette $tocktean 95212 Alm—Or's 137-31-10 <br /> tart=LL Location - CMS3 Sheet City Zip Parceo <br /> �u <br /> rRt7Ps=RTYOrrmr IBPOE of Lod ael0%l hmo P.O.Sox 691985 City Stockton Z'i095212 Phone# <br /> C.57ContmCtorVironex, Ince Address 23726 Foley St. #7City HaywardMp94326ti,_v7059�*Oney 510-266-0966 <br /> ConsuttsM/Sub Contractex Twining Labs, In2.,gddrM2527 Fresno St. City Fresno Lim phwev 559-268-7021 <br /> GIS CAardlrtatas:X Lat 37 57. 365 YLong 121 17.47 3rowft* Range Section <br /> WORK TO SE PERFORMCD <br /> �{NEIN WELL/BORING(CPT. FOPROS -KYOROPUNCH. HAND-AUGER.OTfiEft'i ji pESTRUC1lON{or+oo4e tXpe beknwl <br /> (3 0tf BORING a 0 OVER-BORE <br /> "Ower WELL 0 SWI,6; ;4 ;id3 rg;z3,-SW4 a PRESSURE GROUT <br /> COMMENTS_ <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORJNG a HOLLOW STEM Dtk OF BOPJEH04.:. 1 1 I�ULTIPLF-GASiNGS?p YES NO VyEU CASINO DPA <br /> EXTRACTION p AIR NAMMER1DRfVL'rNf GA31NG THICKNE$S NAT,..TYPE OF CASING: a STEEL Pvc 12 O'TX6Ji <br /> ' VAPOR MUD R0 AAY DEPTH OF GROtT Sl AL 3REZ 5 TYPE TO BE USED: GAUGERS aHCSE <br /> AIR SPARGE PUSH Potwr GROUT SEAL PUMPED- a YesS ff't (NOTE: MAXIMUM FREE-FALL DEPTH tS 30') <br /> 0 SOIL BOPoNG 0-KAND AUGER APPROX.BORING OEP'TH n$OLTED TRAFrIC BOX or U STOVE PIPE <br /> ' a OTHER CONDUCTOR CASING PROPOSED? {If YES.I-ist sp}ecAustion6 here): <br /> COMMENTS.- <br /> NOTE- <br /> OMM NTS.- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> hereby certify that I have prepared this application and that the wort wil be bone m aot:ordance with San Joaquin County Ordinances,State Laws.and Rue— <br /> and Regulations of the San Joaquin County. Hameowm or frcensed agent's sigmure c ed fies ttfe fosowituy 11 certify tfrar in the performance of 1lte work <br /> for"IC17 ells pelma fs issued.1 shall not employ pwwana srrbicct to KVRKMAWS COMPCNSATTCN Ls"of Callfomis.. Contmetof C hiring or suh- <br /> contracWv signature cedifm the fonowmg: "conffy dw in the perbTonpe o/ v worst for wtkm this PWM 7's iswed. I-%hail employ peitvm zLtOCt to <br /> INt RKMAMS COAVENSAnON Laws of CaRbmia_' <br /> 7H .APPLICANT MUST CALL 40 HRS IN ADVANCE FOR ALL REQUIRED INSPl=CTIONS. <br /> Signed x//41//"1 t 7it1e )k- 11n✓r s7. . 4,�n�✓r ,Date t��6/ Y <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 12/6/99 <br /> OP-PARTMENT U31!ONLY <br /> Apok ation Ac*Wed gy Datr Ism Area <br /> Grout Inarmeti4m By Date Firt7PI Imoertion Ey Date <br /> Oestruction Inspection By Date <br /> COMMENTS 1 CONDIYIONS: <br /> A0=UN`i'IN0 ONLY. AID# FAC# <br /> PE CODES FEB INFO AMOUNT REMi771=D CHECK#;CASH REC,EJVF-D BY PATE PERMITISiERVIGE REQUEST NUMSFR � INVOtc <br /> 1 � <br /> UNIT N—5199/mi <br />