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U t, <br /> WELL PERMIT APPLICATION FORM UP41T IV <br /> SARI JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Pp4--kiENVIRONMENTAL HEALTH DIVISION (PHS•EHD) W <br /> 304 E.*Kober,Third Floor,Stockton.CA.,95202 <br /> (209)468-3449 <br /> NONAMM&DA84.6 PENT BXs+lRg31 YEAR FROAA GATE 19SUED <br /> Apotigtlon is ho^eby made to San Jaaquln County ter a porn*to construct andtor Inatalt tho work descrbsd. This application is made in aomplianoo With <br /> Sen Joaeglln County De opment T o, ha r 1115.3 and the Standards of San Joaquin County Public H=ith Services,Environ naotai Hoalth OMisjo,. <br /> WELL Location • Cross Strom-PLO*—. City <br /> PROPERLY Owner yy Addtass 7 • cjh ZEhon �j <br /> e�P C liGQx h0 <br /> C-67 Contractor <br /> d P= <br /> Consultand/Sub Contractor_&, UWEno <br /> Pho <br /> GIS Coordinates:X Y Township Range SWon <br /> WFv WTO BE�PVERFORMED <br /> Q NEW WELL/BORING(CRT EOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION C c w W below) <br /> SOIL BORING a <br /> Q LL 0 Q PRESSURE GROUT <br /> ,other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE C <br /> 1]MONITORING 40-8jiOLLOW STEM DIA.OF BOREHOLE 'I ft <br /> MULTIPLE CASINGS?Q YES 11 NO WELL CASING DIA.Q EXTRACTION a AIR HAMMER/ORIVEN CASING THICKNESS_ TYPE OF CASING: a STEEL 0 PIV'C p OTHER: <br /> 3 VAPOR D MUD ROTARY DEPTH OF GRWT SEA TREMIE rYPE TO OF-USED: "ERS jIIOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: U Yes 0 No (NOTE:NAMUM FREE-FALL DEPTH IS 30') <br /> �92OIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 8OLT'ED TRAFFIC BOX or p STOVE PIPE <br /> Q OTHER:_ 0 OTHER CONDUCTOR CASING PROPOSED? (M YES,list%1=11cations twro): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby oer*that t have Prepared this sWicatior,and that the work will be done in accordenoo with Sar.Joaquin Mnty Ordinance*,Staft Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifias the following:"1 certf oat In the poAbnncnoo of tho www <br /> Aw which this=to issu",I shed not emooy porsens su*w to WIORKE",COAfPE sAT/OAf Lama of CaflJbrrtio" C.6miactors hinng or sub. <br /> contrscCrg signature Comities the following:'I Certify that in tho penbmranca of the work for which this permit is Issued,I she#onV*y persons subject to <br /> WORKERS'COblPENSA nON Lows of CaR}breia.' <br /> CA 7HE;UNkT11f I, TOft 8.1NOttiCtIV4;NtiN AD�/ANCE.FSR:AL F(EQtJ�Rtmn <br /> INPECTIO�IS. <br /> Signed x Titb/Company Isr►Q — <br /> Owl <br /> Print Na Ca <br /> OEPARMENT USE ONLY <br /> Applicator Aeeeptod By Orate Issued !/� � ,• L;c _- <br /> Grout Inspeetior.By Data Final Inspection By -—Date__��a <br /> DesvuCtion"Pection By Date <br /> COMtAt AT I.0 DIMN3: <br /> E S4,f =&Z 4021 QZI <br /> EAC7COUNTnING ONLY: AiDO <br /> FEE INFO AMO* RENiTTEa CHECK0 RECO 8Y DATE PERNT I SERVICE REQUEST a INVOICE <br /> Safi 112.0 2 !4712, <br /> 1/18/2000 <br /> �dX3 <br /> Z0 39dd SOANS039 NOIIV609188-996-80V r8:b1 000Z/8Z/Z0 <br />