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WELt'PERMIT APPLICATION RIM 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 /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,)Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location IVMN S� N w l{ Cross Stree�VY3�City�7 � Zips—23 <br /> Assessor's <br /> r1s3.-/C -Z) / <br /> PROPERTY Owner)�L6W,1LI41-d1� Address��.�%`c�,W i,/4 w/{hls A rT&ity rtlYS ZipCxZ3pl PP,hone# *3- ZS3�NL <br /> C•57 Contractor WPi5L 9AL I1Nf1'1 Address 229 !ter Z City Zip x Lic#551!/P /�70 <br /> �1, ��,a1_� hone# <br /> Consultant/Sub Contractor AOL-L- 5� Address Wly, ,y���City re�A Phone# x'07 <br /> GIS Coordinates:X , Y Township Range Section <br /> WyyyOR��'K TO BE PERFORMED q ` <br /> WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) O DESTRUCTION(choose type below) <br /> O SOIL BORING# 0 OVER-BORE <br /> O WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �VONITORING ,,HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?O YES ONO WELL CASING DIA: z1f (� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC O OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALSVrJV,(e TREMIE TYPE TO BE USED: GAUGERS OHO <br /> O AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes Oio (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH I5 f DLTED TRAFFIC BOX or O STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: 1140A, <br /> ' <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 Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> QIALIA1L,TTHH,,E UNIT <br /> �,AI�V�INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed Vl/�J"Y[fhU'iJ�77:) Title/Company AO-t:- <br /> Print Name lMl l�f %(� Date <br /> SEE SITE;,MAP IN UNIT IV WORK PLAN DATED-- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By CbIA4A r9f2lk- Date Issued i; Area <br /> Grout Inspection By r- \ Date S OCU Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 10 g�.ov ,do n� S a' S R# C2 QZZ 54 <br /> 1/18/2000 <br />