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0-id-1999 9:50141\1 FROMU P Y <br /> '%.v FILf <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> .�3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EMD") �'� <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 t(a ED <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Apotication is hereby made to San Joaquin County for a permit to construct andlar'etrstsu the work descr;bed. This application s Envy made <br /> i ncot3l HeaRh Division. <br /> San Joaquin County pevelppmeni Title,Chanter 9-1115.3 and the Standards of San Joaquin County As$"W's <br /> WELL Location ,22 N C ( O Cross Strott('jAcna_.wo <br /> S .City y:53.0, � Z,, ?arceW <br /> PROPERTY Owne Ill. - <br /> Address 1 eiry �ZiP�LPnonete[4 )B,�R-t16by� <br /> V w ,,�! �, 5 l 1 t Phonert 767-37Y-Z8I S <br /> C•s7 Con s 7- 7_Zv yJ1.Z_Address _ C+ty�o lv�Jtu Taa�S�S7) <br /> Q��-, f:s„ �N ! Address 20Coros�ro�,; City Phones ?�F9.6`1d-Z696 <br /> Ma <br /> Consun2!Sub Contractor .6 <br /> 11 <br /> GIS Coordinates:X <br /> Y .Towns" Range Sectio <br /> /YORK 70 BE PERFORMED <br /> �,pESTRUCTION(choose type below) <br /> G NEW WELL/BORING(CPT.GEOPROBE HYDROPUNCH.MA►`1D-AUGErZ.OTHER-) � 666___��• OVER-BORE <br /> 0 SOIL BORING 9 a�- PReSSURE GROUT <br /> 0 WELL r /Lcw. <br /> 'ether. <br /> COMMENTS: <br /> YpE ELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DW- <br /> ? <br /> mONTORING G HOLLOW STEM DIA.OF 3OREHOLE MULTIPLE CASINGS.'G YES G <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> EXTRACTION 0 AIR;tAMMER/DRIVEN CASING THICKNESS t 1KIE TYPE TO 3E USEO G AUGERS OHCSE <br /> MUD ROTARY DEPTH OF GROU r SEA~ <br /> a AIR SPARGE 0 PUSH POINT GROUT SEA1.PUMPED: a Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> G SOIL BORING a HAND AUGER APPROX.Soli DEPTH G BOLTED TRAFFIC BOX or G STOVE PIPS <br /> OTHER: CONDUCTOR CASING PROPOSED? (if YES-less 50ce..-Cations here)- <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> Hereby GGri7tY ttU[77—I Rave preoared this aGpk*tmn and that the wont will be done in acciorcanCe with San Joao County Ord Nem..perElate <br /> La s.and <br /> Ru ks <br /> and Regulations of the San Joaquin County. Horneowner or licensed agent's signature pertiTies the t A77ON - certify ConlraClors hiring Or <br /> ,or which this permit is issued.I shall not amPloy Persons *wk subject ry tI'OR '�a � S� d is issued employ persons w sut� <br /> :ontracting signature Ce e t ng: certify that in tha POA110M M& <br /> �prZC MAWS GO _lVSaTION wS of <br /> TE AP LICANT r CAU.48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> rale f r I r'I GI p aXeDate <br /> Signed <br /> T PEVO(z SAlll'TOCHIZ <br /> SE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued / � Area <br /> Aopli=tion Accepted By <br /> Grout Inspection By Date - Fins!InspeWon BY Destruction Insoection Sy Date Z'l <br /> C Z9i 17-7 <br /> COMMENTS/CONDITIONS <br /> I FAC>Y <br /> ACCOUNTING ONLY. AIDa <br /> PE CODES FEE INFO AMOUM REMITTED CHECKSICASH RECSIV>:o BY DATE PERMITlSERVICE REQUEST NUMBER INVOICE <br /> Air R9 <br /> FILE COPY <br />