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Q/V <br /> VVELL P5RMIT APPLIGA.TION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l Z' <br /> ENV?RONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE COPY <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 Tnis application is made in compiiance with <br /> San Joaquin County Development Title,Chapter 9-1'15 3 and the Standards of San Joaqu n Count/Pubic Health Services, Environmental Health Division. <br /> Gt-!/etu/07o7 170 s�jtKfrc zip 2tS Pzrcel#Assessor/17- I/f <br /> WELL Locatlon2701 P'W IS/�J't'�01-k _Cross Street N�i_vtey City _ <br /> it <br /> PROPERTY ONner���z j55;ziR Address 2721 N. (/4fa �J2�Gity x.A2- zip8t�0041!` Phone# <br /> C-57 ContractorPV-e-ClS1%bA r` Acdress1%0 5Z>"- 5f. —City Rl�-kmDaZic!1400YLic# Phone#$C010-67/• 17" <br /> Cor:sultant/Sub ContractcrDlQ2S Git✓ria' CMG-/Address2.,->ZeF td-d bo. MIRE?C,ty A2 Lim Phcne#�2-7 Z-8-6�d7 <br /> GIS Coordinates.X._ Y _ Township Range Section <br /> WORK TO BE PERFORMED <br /> �C7NEVV WELL r BORING(CPT,GEOPROBE,HYDRGPUNCH.HAN^-AUGER,OTHER-) 0 DESTRUCTION(cnoese type below) <br /> C SOIL BORING#_.5ZAt �;K- AUGER, <br /> a OVER-BORE <br /> [I WELL# a PRESSURE GROUT <br /> 'Other:_ <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> If <br /> 9 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 7—"*7—"* MULTIPLE CASINGS? a YES []NO WELL CASING DIA: Z <br /> a EXTRACTION 0 AIR HAMMER;CRVEN CASING THICKNESS TYPE OF CASING: 'STEEL 0 PVC 0 OTHER <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS QHOSE <br /> D AIR SPARGE `KPUSH POINT GROUT SEAL PUMPED X'Yes p No'(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> X,30!'-BORING I]HAND AUGER APPROX.BORING DEPTH I/O r _____[]BOLTED TRAFFIC BOX or I7 STOVE PIPE <br /> a OTHER_ 1)OTHER CONDUCTOR CASING PROPOSED? Mo 1:if YES,list specifications here): <br /> COMMENTS: Se Pia,- ✓ r4,-'IS _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work wi'l be done in accordance with.Sar Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the Sar Joaquin County. Hcmeowner or licensed agent's signature certifies the foilowing: 'Y certify that in the performance of the work <br /> for which this permit Is issLed, I shall not employ persons subject to WORKERS'COMPENSArICN Laws of Californla." Contractor's hiring or sub- <br /> ccntracting signature certifies the following: "I certify that in the performance o'the work for which this permit is issr_-ed, 1 shall employ persons subject to <br /> bVORKERS COMPENSATION Laws of Cafrfornra <br /> HEhL .:; _"�+ ±�! ..' tttKii1rf7 #N€ 1E 4�11jEt fSiE± t(3 <br /> S,gred r. Titie���� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: ���3-l� 2v.�'� /d –/Y ? <br /> DEPARTMENT USE ONLY G Q <br /> Appilcation Accepted By Date Issued l0 -7// �/ Area <br /> Gaut Inspection By Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS lIU !✓ <br /> ,ACCOUNTING ONLY: AIC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REO EST# IN 1k,ICE <br /> l �83 01 2100 i <br /> C-57 LICENN E ?.GONF'R 3 GTC�F�A/�Lr�t,;SiCiti�r;LI CE SS& C KE;�S i`404?F�7�St TJO-ibtCL.A .ATI( N <br /> tlNIT T_V-6,'23/99/sign bkpg/MI <br /> Z •d v iC?' WdL`:''7 666 l-l am- <br />