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09126/2001 120!13 2094683433 FIFTH F1-00R PAGE 07 <br /> -' --'-- WELL PERMIT APPLICATION FORM <br /> SITE <br /> _ - - - M,rrIGATiON <br /> SEP 2 0 Too' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Ei V`i`= 304 E. Weber, Third Poor, Stockton, &1., 95202 <br /> (209) 4684449 , IUr P/� <br /> NOMEFUNDABLE MMrr EXPJRES 1 YEAR FROM MTE ISSUED <br /> ren c abon is hereby made to Sal JoNum C4oursty for a payM to comtrta aWor asstg the wank describer l Th*appr�on is made mnpf,arm wst.'r San <br /> Joaquin Ctunty De++el*merd 71ft Chapter 9-1115 3 and the Standards of San Joaq an Co <br /> ounty Pubtrc Hee,h Sanw&s, Errv�ra+�rr mta(HeaM r rmw <br /> Cross Street 1�' Cdy r Z0 .Z07 Part �9m <br /> WELL.L.ocWon� 10-21 <br /> Ida-2=4tc wy6 �,y,�.q : 3=as'P6 <br /> PROPERTY Owner r t ry � Acfdrrss City zip. Pnon.# <br /> C-57 C. rrbactw Address 226; �C7ty b 41440, 23p •__=•"L r Y-'?-y <br /> Consultant[Si#Coatra 614 -4;9 _ _Address 6 L ►�nek$ CihL Jar/ L, Sr. d`s7 Phones �'S3 <br /> GIS CoatJrnates X Y R - Sens <br /> WORK TO 6E PERFORMED. <br /> p NEW WELL f BORING(CPT,GEOPROSE,hTDROPUNCH,HAND-AUGER,OTHER-) VESTRUC- s 4'fpe bek wy <br /> 0 SOIL BORING,# _ _ <br /> gt~LL# — -��hcoq ' �ESSUR RGROtTF <br /> 'Other F'. �^ OrcaSpecrficabl MMX H!j� I+Z<- <br /> COMMENTS ; <br /> TYPE OF WELL INSTALLATION TYPE Ct?NSTRJCTIOM SPECIFJCA11ONS <br /> 0,}I}MONITORING D HOLLOVV STEM DIA.OF BOREHOLE MULTIPLE CASINGS?8 YES Q NO WILL CASING DIA <br /> EXTRACTION p AIR HAMMEWDRIVEN CASING'THICKNESS TYPE=OF'CASING D STEEL D PVC tI OTHER <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SSAL T�F2I�EMIE TYPE TO BE USED 10 AUGERS 0 HOSE <br /> D AIR SPARGE p PUSH POINT GROUT SEAL PUMPED- U Yes D No (NOTE` MAXIMUM FREE-FALL DEPTH lS 30') <br /> 0 SOIL BORING tI HAAID AUGER GROUT SPECIFICAT74NS t <br /> U OTHER it OTHER APPROX BORING DEPTH a BOLTED TRAFFIC SOX I or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_- —- (if YES,Jsst speufoatlons here) <br /> *COMMENTS <br /> NOTE: 'OFFSITE BORINGS REQUIRE ACCESS OR ENOROACHMENT PERMITS. <br /> CALL,THE UNIT W INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify/that I have prepared this appl(catlon and that the Work mli be done In accordance wth San Joaquin <br /> County Ordina 5, nd Regulations,and all applicable Caitfornra Stat Laws, <br /> Sgmd x Tr�a+Casypany �' 741 - <br /> Pnnt blame - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6*5- <br /> WORK PLAN DATED'. ,- 0) <br /> y f <br /> Rppil�trm Ac-,Wed By Data Jsse+e�d069 <br /> �,- <br /> Grout Inspeoum By. Date FJnad Inspscftn D� <br /> oestrucam Inspection By Oats <br /> cOMRItems d CONDrTIONS <br /> ACCOUNTING ONLY AI0# <br /> PE COOES FEE INFO AMOUNT REMC TED CHECKS REED BY DATE PI RMtT J SERVICE REQUEST 4 INVOICE <br /> sa <br /> r_57 Wr -WATVJ=O 'A'r I •+tor of to<gnn normi� FnrrivtrJt+nont rinr 0/771ror <br />