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06/05/2002 08 51 2694683433 FIFTH FLOOR PAGE 02 <br /> i <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 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appl Gabon s hereby made to San Joaquin County for a permit to construct andlot rngtall the work described This application is rade in corrlpliance wdh <br /> San Joaquin County Development Title Chapter 9 1115 3 and the Standards of San Joaquin County Public Healtr Services Environmental Health Divisor <br /> LA-16,Y <br /> �l _ 1 Assessors <br /> WELL Locat(an 0 Q) r �/`'� Gross Street ����> a- fs C ty eeiC ZIp__}2,C_�Parcel# <br /> rJj <br /> PROPERTY Owner r SI. r►1 Address SSG L�. Pi <br /> C-57 <br /> .Phone 'Y� <br /> C-57 Ccr�tractoGT-2. _ !.ti_Address Cuy J r'�`�_Zi_pLL+Z�-L'*- O_IPnone# X13— SSf 4 <br /> L : FV Qo consultant tSub Contractorn _ dC ty2oL Ux69Z- Pncne#L Q�S'��� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> a NEW WELL 1 BORING(CRT GEOPROBE, HYDROPUNCHAHD AUGER OTHER') 3ESTRUCTIONOvER BORE t p below) <br /> SOIL BORING tFGPT- IO�GP'r 13 PRESSURE GROUT <br /> Q EL # <br /> 'OtherG tY� <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DEA OF BOREHOLE Z-`f MULTIPLE CASINGS?a YES',RNO WELL CASING CIA <br /> EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS AIA TYPE OF CAVNG D STEEL. Q PVC p OTHER <br /> VAPCR 0 MUD ROTARY DEPTH OF GROUTSEAL � TREMIE TYPE TO BE USED B ALIGERS ;-HOSE <br /> AIR SPARGE )WJSH POINT GROUT SEAL PUMPED Yes 8 Ng (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> -8:: OIL BORING Q HAND AUGER APPROX BORING DEPTH PIPE <br /> . <br /> [] OTHER a OTHER CONDUCTOR CASING PROPOSED?�Q (dYE5 list specifications here) <br /> COMIMENTS,-,_ <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 Ordmances Stats Laws and Rules <br /> and RegLlstions of the San Joaquin County Homeowner or licensed agents signature certifies the foli r cenlfy that in the performance of the work <br /> for which this permit Is Issued,1 shall not employ persons subjW to WORKERS'COMPENSATION Laws of Cabfornta" Contractor's hiring or sub- <br /> contracting signature certifies the following 'I certify that on me performance of the work for which this permit is issued I shalt employ persons subject to <br /> WORKERS NSATION Laws of Cabfomte <br /> ALL E UNIT IVINS EC R &WORKING HRS IN ADVA CE FOR ALL RE HIRED INSPECTIONS. <br /> S gned K L / IolCompany I <br /> Print Name �✓ Date <br /> �t �l4}�'t �r' h <br /> DEPARTMENT USE ONLY <br /> Appi Accepted By Me Date Issursd_. <br /> � Area I <br /> Grout Inspection By Date Pmol Inspect,on By Dats <br /> Oestrucnan InSDection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY A09 <br /> E CODES Wn INT REMITTED CHECK r REG D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />