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L <br /> WELL ►-ERMIT APPLICATION FOR 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 I YEAR FROM DATE ISSUED <br /> Application o he.eby mage to San doagwn County for a permit to construct andror instal!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 DIVIF ion <br /> C / Assessor's <br /> WELL Location (0 74 Gt,� 0L114 1C'll(� Cross Street m 5 City 40e Wfi) 'LZrp Parcel# <br /> PROPERTY Owner L & Address n City u+Oti1. 2�p gPhonef� tr10�6 dD <br /> tordDv- C_S� G,,,� <br /> C 57 Contractor ,(�, k /.Add1ss ( K w Clt (a+ 9" p�ULrct2 6[1`PhonarktYtt fi3 '3583 <br /> Consultant ISub Contractor <br /> fib�l1/!(�Ailid4esa ( C�tyG� Lrcrl$�S� Phone#� ��13"�—Zl�o <br /> awW a� c f <br /> GIS Coordinates X Y Township_ l� Ran9e_ _ Section _ op <br /> WORK TO Bg PERFORMED <br /> NEW WELL!BORING(CPT GEOPROSE HYQROP NCH HAND AUG R OTHER-) ! p DESTRUCTION(choose type below) <br /> DIL BORING a Q OVER BORE <br /> WELL# Q PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORINGHOLLOW STEM DIA OF BOREHOLE_„_MULTIPLE CASINGS?p Ycs,,bSb WELL CASING DIA <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS`TYPE OF CASING p STEEL ©PVC o OTHER <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS OHOSE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED Byes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX BORING DEPTH (go a 60LTED TRAFFIC BOX or n STOVE PIPE <br /> Q OTHER p OTHER CONDUCTOR CASING PROPOSED1 rd (if YES list specifications here) <br /> OMMENTS Irl t 5D ' �Q to t s wa y- <br /> cw. s • •R G,ZctieaE <br /> NO E' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this apphcatrort and that the work will be done in accordance with San Joaquin County Ordinances State Laws Incl Rules <br /> and Regulations of Oe San Joaquin County Homeowner or licensed agent s signature certifies the following 'f certify that in the performance of the work <br /> for which this permit or.issued l shall not employ persons subject to WORKERS'COMPENSATION Laws or Cafrfomra ' Contractor s hiring or su5- <br /> contractrng signature rartifies the following '1 certify that in the performance of the work for which thus permit is issued 1 shall employ persons sub/ect to <br /> WORKERS COMPENSATION Laws of Ca0brnrs <br /> THE APPLICA1IT TCALL48'WORKINGHRSIIN`'ApVJA)I!'1C1t,FORALCRF_CIUIREDINS�PECTIONS. <br /> Signed,, ex r r• J' t0ld�GiS4Prty(�8Et7SrSJ- _Date OZ <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 7-A <br /> DEPARTMENT USE ONLY j <br /> Application Accepted By <br /> Date Issued 34-2 1 R rte—i Area <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By Data <br /> I <br /> COMMENTS!CONDITIONS <br /> i <br /> i <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC-D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3S r 7 a� <br /> C-57 CE �"Q0 'ACT R,90 ,SC�.PE'FA� � AISI; MS _O � � _ <br /> UNIT IV-6/23/99/sign bkpg/MI <br />