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12-10-1999 12:33PM FROM P• 2 <br /> WELL PERMIT APPLICATION FORM 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) 46&-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.,1[115.3 and the Standards of San Joaquin County Public Health Services, Environmental Heatih Division. <br /> WELL Location DI�TC S/t4iPP ��p/7-k%/ crosss4I eet/ K04G� City F(Pm�,(,� f�,p Zip !SParcegt r s <br /> PROPERTY Owner P-�u7sr �n�s gHcy �To,3ofc Yooae/ City SrOn�fyK Zip (� y�hone# C(—�Y- <br /> G '�'`] i q1I IAV" �o� marTll• NS53 u ± ylp3i3"rbOd <br /> CST Contractor /Q Addre.�ls City Zip�Lidfl�Phone# <br /> Consultant h6eb6eMre0tor 4Qs,�,/Q,p&hl ht•// Address t°3�/G!Q®/O</ids e city e _r7Lwe+#= Phone# /4 -�hZ-��3L <br /> GIS Coord aces:x r30710 7 ��Y 33�3Y/ (60 Township �� Range / L� Section •—�'� Z 1 <br /> WORK TO BE PERFORMED <br /> YNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'LQ DESTRUCTION(choose type below) <br /> BORING <br /> WELL# ICWL Fr�/Gy 0 OVER-BORE <br /> *Other: r i 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL IPTALLATION TYPE CONSTRUCTION SPECIFICATIONSSt>' e6/IhoF / <br /> U MONITORING HOLLOW STEM DIA.OF BOREHOLE U MULTIPLE CASINGS? Yee <br /> NO WELL CASING DIA: b <br /> >XTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING: U STEEL ,';RkVC BOTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 60 TREMIE TYPE TO BE USED: Q AUGERS *OSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: xyeii ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER APPROXI BORING DEPTH Z$L Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER: tt OTHER CONDUCTOR CASING PROPOSED? ( f YES,list specifications here): <br /> COMMENTS: S5r� ? Z I� LYIs 'Ti,/f��P 'F j1 u.r0 <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 doe 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 cerUry 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 /> y..�.._a�. <br /> Signed x Title Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> ' n DEPARTMENT USE ONLY Ani <br /> Application Accepted By v'nA-(�" Date Issued 7/l a fy Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAQU <br /> ;PE CODES FEE INFO AMOUNT REMITTED CHECKO RECD BY DATE PERMIT I SERVICE REQUEST# INVOICEq .ol $�1 ' }7z y31 l 711600 Sg# 66Y3361 <br /> . a <br /> I_. .._-.. <br /> UNIT IV-6/23/99/sign bkpg/MI <br />