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• WELL PERMIT APPLICATION krRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE FILE <br /> � <br /> ENVIRONMENTAL HEALTH DIVISION (PHSD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 1: J <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 /> Assessor's <br /> WELL Location 290 N. Yfdn SIz6e't Cross Street Ncic'th Street City Zi.r)95336 Parcel# 223-091-01 <br /> PROPERTY OwnerE lord & Ialr_I>res l r']LL10zd ABdress FO BOX 1022 City NtfflbeM Zip95336 Phone#209-239-4141 <br /> C-57 Contractor V&W D ill M AddressF0 BOK 51 CityMO Vista Zip21 ?1 Lic#tT-'0904 Phone#707-3742815 <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> IF NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 1]DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# 3 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING /HOLLOW STEM DIA.OF BOREHOLE � r� MULTIPLE CASINGS?a YES w NO WELL CASING DIA: Z t� <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Lio TYPE OF CASING: p STEEL I PVC Q OTHER: <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2t r TREMIE TYPE TO BE USED: Q AUGERS $HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: u Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH L 1 T4 I BOLTED TRAFFIC BOX or O STOVE PIPE <br /> Q OTHER: fl OTHER CONDUCTOR CASING PROPOSED? IAZ_(if YES,list specifications here): <br /> COMMENTS: cep a{}ar}rr� rrai <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/s Issued,I shall not eunploypersons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that M the performance o/the"t*for wnrch Ibis permit is issued,1 shell employ perrsons subject to <br /> WORKERS'COMPENSATION La sof Califomie." <br /> T e/kPPLICA 1t1111 <br /> ST BALL; .ltC1N} i l�# '1N k7��iI1111�tC f+iyL�, - 1 NB <br /> Signed x F7 Title / Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY Q a /�/ <br /> Application Accepted By Date Issued l�' ` ( Areayv <br /> Grout Inspection By Date 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 iL REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 3501 - Ib b(o Cx lI-2— ozio94 <br /> AEGI:ARA*U <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />