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03/22/2002 11: 43 2094683433 FIFTH FLOOR PAGE 03 <br /> s <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> :r a -- <br /> ,•S•�i:l�:EilJi�wf�!_.i'iL?li <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 02 PEAR 19 AM 9. 4 1 ENVIRONMENTAL;.HEALTH DIVISION (PHS-END) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (2091468-3449 <br /> NQFW-RE�EILINOABLEPERMIT EXPIRES 4 YEAl31:ROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a penmlt to oenstruct andfor install the work described. Thts appiiCation Is made in compliance vAh <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> O 5. ,I SAtr1 '' W r Ci4C1 c� q Assessor 6 <br /> WELL Location _ I.[1 tW Cross Street QST,"ylg� y tk Ziip �'�._zow._Parcx <br /> PROPERTY owner C 0 Ir- 5i (2- Address Ra. 65'4q City A ip �'f511DPhone#�279-S"I <br /> f_f 11 d ,?o. BwX 336 rs e Fly- <br /> C-57 Contractor W4ai, Jw for ddtes9 pCity�ia i3i - gip �f� Lic#7f 6 Phon <br /> ConsultantiSub Contractor l}$_ EA1111CW'_ �Address�e�.ek tP�is S5_o _Gity Lic#�_Ph onc#,�5, 0676-6� <br /> GIS Coordinates;X 'Y Township Range Section <br /> )NORK TO RE PERF=ORMED <br /> `ANEW WEU-1 BORING f CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTKER-) a DESTRUCTION(choose type below) <br /> OIL BORING# _ 0 OVER-BORE <br /> WELL#� I Lt1 -L _"' l W - 5 fl PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELD INSTALLATION TYPE CONSTRUCTION SPECINCKnONS <br /> Q MONITORING `9 HOLLOW STEM DIA-QE 130REHO�E�y MULTIPLE CASINGS?n YES ANO WELL.CASING DIA � <br /> a EXTRACTION aAIR HAMMER/IDR1VEN CASING THICKNESS 44> TYPE OF CASING: p STEEL XPVC Q OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAS. 50' TREMIE TYPE TO BE USED; JFVAUGERS OSE <br /> AIR SPARGE a PUSH POINT GROUT'SEAL PUMP€G st p No (NOTE: MAXIMUM FREE-FALL DEPTH IS30') <br /> ti SOIL BORING E HAND AUGER APPROX.BARING DEi'7H 5 r BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER;_ _[{OTHER CONDUCTOR CASING PROPOSED? {if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that i have prepared this application and that the work will be done In accordance with San loequin County Ordlnances,State Laws,and Rules <br /> and Regulations ofthe San Joaquin County. Homeowner or licensed agent's signature cert.Mtr the following:"f eerfify that in the pediormanee of the work <br /> for which this permit Is issued,i snail not empioypersons subject to WORKERS'COMRENSAr)ON!caws of Ceiilomla." Contractor's hiring or sub- <br /> contracting signature certifies the fallowing: T certify that in be performerrxv of the work for which this permit is issued, l Shall employpersom subject in <br /> WORKERS'COMPENSATIONLaws ofCalilarrria." _ _ <br /> In <br /> OWN <br /> S+gncd K Title 7ex1tioma ' Date ! 7 Z' <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By. 2P fid. lE.t u _ Date Issued -:3L7�O-_-P— <br /> I Grout Inspection 13y Datefinal inspection By Date <br /> Destruction inspection By Data <br /> COtt MIINTS I CONDIT10NSr <br /> ACCOUNTING ONLY: AIDO FArld <br /> PE CODES FEE INFO AMOUNT REIUFLTTED CIJEECK.it {/3,y2/ECCC'.D 9Y DATE PERMIT/SERVICE REQUEST 0 iNVpiCE <br /> SR <br /> w-�. - .vn..• . <br /> UNIT LV-6/23/99/sign bkpg/NLT- <br /> i <br /> I <br />