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06/05/2002 08 51 2094693433 FIFTH F'-DOR PAGE 03 <br /> 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 MAY 2 4 2002 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � � � � �� <br /> mwfiaawz <br /> Appl;canon is hereby made to Sap Joaquin County for a permit to construct andlounstall the work described Thls appltcahon s o <br /> San Joaquin County Development Tale Chapter 5-1115 3 and the Standards of San Joaqulr County Public health Services Environmental Health Division <br /> Assessors <br /> WEAL LOCaGor W- r"`' CT Grss 5treer:r-nki:-34S City skc-0 <br /> Z p-1'.� Pared# <br /> PROPERTY Owner.st".l� �. _CAI dddress SP1 O.Z-A �J369 _city txt 2+�1�C' Phone <br /> C S? Contractor Gr Add,ess,[� t 7� * City;t L'���► PhonO r ZS 3 3'Sf' <br /> Consultant?Sub ContraGo Addre55 T.a.QoK 77_011 y So�7Q L . ^phcne4fC)4 <br /> GIS Coordinates X Y Townsh p Ra nge SC&on <br /> WORK TO 13E PERFORMED <br /> ` 4EW WELD 18OMNG GRT GEOPROBE HYOFZOPUNCH HAND AUGER OTHER-) p DESTRUCTION(choose type below) <br /> SOIL BORING J3 OVER-BORE <br /> a WELL 0 0 PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MON TOR NO I]HOLLOW STEM DIA OF BOREHOLE��Z—'`'-rMULTIPLE CASINGS?p YES $NO WELL CASING DIA <br /> EXTRACTION I?AlR HAMMERfDRIVEN CASING THICKNESS 0 TYPE OF CASING [I STEEL 0 PVC p OTHER <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL q r/ TREMIE TYPE TO BE USED R AUGERS NOSE <br /> (]AIR SPARGE PUSH POINT GROUT SEAL PUMPED ' Yes 0 to (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;SOIL BORING 1]HAND AUGER APPROX GORING DEPTH a BOLTED TRAFFIC BOX or d STOVE PIPE <br /> p OTHER 0 OTHER CONDUCTOR CASING PROPOS Eao�lr; {,f YES list spec fcatlons here) <br /> COMMENTS Gro aWC 0h' <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cert fy that I have prepared this appucahon and that the work will be done in accordance with San Joaquln County Ordinances State Laws and Rules <br /> and Reguiat ans of the San Joaquin County Homcewner or licensed agents signature certifies tht following 'I certrty that in the performance oFthe work <br /> for which this permit is Issued I shall not employ persons subject to WORKERS'COMPENSATION Laws of California' Contractors hiring or sub- <br /> conlracting signature certifies the following 'I ca rhatIn tho performance of the work for which this permit J-9 issued I shall employ persons subject to <br /> WORKER C NSA -ION Laws of Call a <br /> ALL E UNkT IV INS EC 48 WORKING HRS IN ADVANCE FOR Atf, RE INSPECTIOMS <br /> Signed: T tle/Company <br /> Pnrt Name Date <br /> �" "'`n •a nl hid+� " <br /> y lw <br /> DEPAFZTMENT USE ONLY <br /> App;-cat on Accepted By r Date issued y Area <br /> Grout Inspectuan By Date Final InSPOCtLOn By 09ta <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT R MITTED CHECKS REC D BY I DATE PERMIT I SERVICE REQUEST 9 INVOICE <br /> v18/2000 <br />