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11/28/2000 11 39 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 131VISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA_, 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEI] <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 San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Servloes, Environmental Health Division <br /> Assessor's <br /> WELL Location �O /�Iq cS`l, Cross Street� 'e Crty A �e Zip - � y Parcetri -7 G 7C <br /> It <br /> PROPERTY Owner2n _[-Mann , _—Addres% J?J+ F i=,j.u _ Clty A Zip�rJ3�PhonG#1 C 1 23-s2 SLS <br /> C-57 ContractorLre_5� e Address City��Zjp s`.S` <br /> wLicify�S!1, Phone#i4.?.f--.�J ��r�O <br /> Consultant/Sub Contractor C .sl.r.Csmtr.a r-,5yu L.,1, ==Address S h S�_ City��aKkr�Lic# Phone#�c ,g7co <br /> GIS Coordinates X .Y ,Township Range Section <br /> ' WOR <br /> KTO BE PERFORMED <br /> R<EW WELL/(ORIN CPTHYDROPUNCH HAND-AUGER,OTHER') II DESTRUCTION (choose type below) <br /> OIL BORING# S $— I _ OVER-SORE <br /> 0 WELL# Q PRESSURE GROUT <br /> "Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE ,eZ i' I MULTIPLE CASINGS1 0 YES 0 NO WELL CASING DIA <br /> 40 EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS IV^ TYPE OF CASING 0 S7EEL [1 PVC []OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /2____TREMIE TYPE TO BE USED GAUGERS OHOSE <br /> SPARGE Q PUSH POINT GROUT SEAL PUMPED {]Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING p W ND AUGER APPROX-BORING DEPTH yL L. —[I BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 0 OTHER THERCONDUCTOR CASING PROPOSED" A.^ (of YES ilst specificabons here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 cortlfy that in the performance of the work <br /> for wh,ch this permit Is Issued,!shall not employ persons subject to WORKERS'COMPENSA17ON Laws of California" Contractor's hiring or sub- <br /> contracting signature certifies the Following !cerfify that in the perforMSinoe of the work 10r which this permit is issued,I shalt employ persons subject to <br /> WORKERS'COMPcNSAT10N L.aw 3 of Cabfarn'a" <br /> C <br /> THLEVNIT-ig INSPECTOR 48 VV0RKW ITS IN;ADVAN0`'01R ALL REQUIRED INSPECTIONS <br /> Signed TittelCompany <br /> Print Name _ jp Date <br /> y� DEPARTMENT USE ONLY <br /> Applicabon Accepted By Date Issued�LL °�� --Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS- <br /> "COUNTING ONLY AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT i SERVIC REQUESTS INVOICE <br /> t/1EI110+,i� <br />