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04/20/2000 06:23 209466343 FI�PTH FLOOR • FILE OPT <br /> (QO? fZ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES b <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> NON-REFUNDABI-E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iance with <br /> Application is hereby made to San joaquin <br /> Chapter f 7r75 3 Permit <br /> to Standards San Joaquin n County Puub c Health. This aServlces.Envipplication Is nronm ntaade in all HHelalth Div sion. <br /> San Joaquin County Development Tile, P Assessor s <br /> y 3 70( 5. 5�. f a Fe Cross Street Cay Qr look zip 95'367 Parce14 ZH4— D�0— <br /> WELL Location 9SSS Sun+4 — lint 75!&8 ? <br /> PROPERTY Owner SAMc PTP Ad�ress 23'7D1 s' eQnlu Fe Qct City nn ipgSi67 Phone# - <br /> �, Zi Q57VL Lic# l5 7q7 Phone#�L BG["7276 <br /> C•57 eontraClor li)e I rz NeL Address 3233 E{v,..... Pr City P <br /> Consultant/Sub ContredorSecoi3r5 ru. tom^-tel Addressklw cltyD�r1+�1.-d�r+Lieg4tyz Pnone#,y� <br /> GIS Coordinates:X <br /> Y ,Township Range Eales Sadlon Lz <br /> WORK TO BE PERFORMED <br /> WNEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) O DESTRUCTION(choose type below) <br /> p OVER-BORE <br /> _SOIL BORING# 0 PRESSURE GROUT <br /> MlELL# —Ej <br /> COMMENTS: t t (°` 5''f . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r <br /> MONITORING ^--->> HOLLOW STEM'�a DIA.OF BOREHOLE•� <br /> MULTIPLE CASINGS?p YES kNO WELL CASING DIA: <br /> U EXTRACTION 0 AIR HAMMERlORIVEN CASING THICKNESS SLH. L40 TYPE OFFEM EITYPETO BE USED �UGERSOTHER NOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL / <br /> PAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: es p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING p HAND AUGER APPROX.BORING DEPTH YD t BOLTED TRAFF�tIo O he e)_ <br /> p STOVE PIPE <br /> p OTHER' p OTHERCONDUCTOR CASING PROPOSED7�Q—(if YES, list sperdt <br /> COMMENTS: — — ( -4V LAO, (Ags <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ith Sty Ordi <br /> I hereby certify that I have prepared this appt�cation and that the wak will as done In acmrdance wan Joaquin Counnanrs,State Laws,and Rules <br /> � <br /> and Regulations of the San Joaquin County Homcowner or tlosnsed agent's signature certifies the following:-i celtlrY that in the performance of the work <br /> Por which this pof thenit S issued,I shot!not employ persons suWecl to WORKERS'COMPENSATION Laws of plifomla." Contractor's s sob'ring oct to sub <br /> - <br /> for <br /> signature certifles the following: I certify Mal In the performance of the work for which this perm%s issued, t shell empty pe 1e <br /> WORKERS'COMPENSATION Laws of Cahforme." <br /> GAL4',jFi 11.N�I IV1k§PtCTOR'485'Wpk�k�RtIG[iRSIN'ADY INCEPOEtI,UYREQUIRED'U�PS,P�L &IORS, <br /> Signed x <br /> .0 CLLGr;y� hEN� Title/Company rr }/mt- 5@lbfL?x-)t, vw.�+�'"ti( Yn.c_ <br /> P ntName S RucL�er�oH� Date <br /> ARTMENT USE ONLY _/ �1 N��(7�' <br /> Apofication Accepted B <br /> Date Issued 7 [ f TT5� Area—t/;r <br /> Grout Inspection By y Date- Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> TI <br /> ACCOUNNG ONLY: AID# <br /> ACCOUNTING <br /> FEE INFO AMOUNT REMITTED CHECK E RECD BY DATE PERMIT(SERVICE REQUEST# INVOICE <br /> Z3 ?- Z <br /> iiLe/z000 <br />