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WELL PERMIT APPLICATION FIRM UNIT IV <br /> S <br /> ENVIRONMENTAL HEALTH DIVISION (PHSREHD)VICES ORIGINAL <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 here 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 Coun evelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> -r l �Ad SfiG UXJ S�pS Assess /s --020 —/4- <br /> WELL Location _?1(31 i6 G.F�e W1Cross Street ,� �✓ City Zip <br /> PROPERTY Owner);0m k J�0/0 Address /01/ 5aAdWV City SrOG Zip 7{1 5 Phone# AS--Q75 <br /> Adi/im1C e-d J�le, <br /> C-57 Contractor 6E!Q&.7a1 W �D <br /> � Nke**tLfAddress ,*%)- J /SD^) City SWCk Zip4576i Lic#0Cr2Z7Phone# 104-7/&066 <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> gNEW b9>`Ett/BORING(CPT, EOPR B HYDROPUN�H,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> rte` ING# ',• 0 OVER-BORE <br /> 0 WELL# y9v�T 0 PRESSURE GROUT <br /> 'Other: T <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 7175 7 MULTIPLE CASINGS?0 YES $6NO WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STErE_L O PVC 0 OTHER: /V <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'f 50*-ACR-- TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> -rSOIL BORING 10`�HAND AUGER APPROX. BORING DEPTH �S"yC+2� I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> O OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <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, /shall not employ persons subject to WORKERS'COMPENSATION Laws of Caiifornia." 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 /> CALL THE UNIT IV INSPECTOR48WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. T- <br /> Signedx � .�f1d►r <br /> ��E Title/Company 5MA"F Geawca 6WrwV/A.,JAW izG <br /> Print Name ( A(,' l CA-\ Date ©r /(e ®c <br /> EE SITE; MAP ,IN UNIT... IV.WORK.PLAN 'DATED:, .a� .� �O _; <br /> ff <br /> DEPARTMENT USE ONLY /) <br /> .: _. . _UNIT,. _w. 0.�, <br /> Application Accepted By Date Issued 7^0 <br /> O AreaO <br /> Grout Inspection By Date Final Inspection By ate <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/SERVICE REQUEST# INVOICE <br /> NO <br /> 1/18/2000�- &� 0023 � <br /> 118/2000 <br />