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03/17/2000 14:31 2094683433 FIFTH FLOOR HAUL bU <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />30+4 E. Weber, Third Floor, Stockton, CA-, 95202 <br />(209) 468-3449 <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct andior install 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 Division. <br />„�/ ��,, Z; e <br />W(=LL Location 3 8 5 �' �' `"^� i I n e 2 Cross Street ��.' /s/City _ 4 P Parcl# _ <br />LL�ZP <br />Pn�o95W <br />PROPERTY Owner <br />y o 6(D WC 20 0 0/ City /%A%"e Zlp YsT3 Lie# 485/GS Phone# ('l 317soca <br />C-57 Contractor 8S-16561 Address <br />Consultant � sub Contractor <br />�,(� S Address �S�Gi/r rlb� r�¢� City �� LiCt Phone# �/6) X64 sSrS <br />GIS Coordinates: X <br />Y , Township Range Section <br />WORK TO BE PERFORMED <br />DESTRUCTION (choose type below) <br />,JFNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HANG AUGER, OTHER") q D OVER -BORE <br />p SOIL BORING 0 <br />0 PRESSURE GROUT <br />{� <br />"Other. <br />5 <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />23r, MULTIPLE CASINGS? 0 YES VNO WELL CASING DIA: 2 <br />�MONITDRING <br />dHOLLOW STEM <br />D AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLE <br />CASING THICKNE55 S<_ti- 4 b TYPE OF CASING: Q STEEL PVC 0 OTHER; <br />D EXTRACTION <br />VAPOR <br />D MUD ROTARY <br />DEPTH OF GROUT SEAL—L-- - 3� TREMIE TYPE TO BE USED: A34UGERS DHOSE <br />D <br />D AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: D Yes _S'No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING <br />HAND AUGER <br />5 BOLTED TRAFFIC BOX or []STOVEPIPE <br />APPROX. BORING DEPTH � <br />CASING PROPOSED?/J/ () (It YES, list speclfications here): <br />D OTHER;__n <br />OTHER_CONDUCTOR <br />Jam/ <br />COMMENTS: <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 done in accordance with San Joaquin County Ordinances, Slate taws. and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the fallowing; "I certify that in the performance of the work <br />W which this permit Is issued I shall nor employ persons subject to WORKERS' COMPENSATION Laws of Calffomia." Contractor's hiring or sub- <br />contracting signature certifies the following: "I certify that in the ps►formance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION ! ews of Califomis. " _ _ �� <br />r N;CE1!F;Qit it li i:# ..E. UIR DlialdS.P' . Y .. i'r#l+�`+. <br />G E rT QN. I'I:iyNS1?E?o.;a... _, �. _.l ..... ° . <br />S�i�►�0.� N A , .�„ .. <br />Title/Company �r A <br />Signed x � .,s .,., ... <br />C_x Date <br />Print Name ---_-. .. r cu�cmya titfldlglCil ilUlll}idflplfll!Iik^1. <br />DEPARTMENT USE ONLY <br />Application Accepted lay C Date Issued C / Z - c <br />Grout Inspection By, � + -P Date l Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: b ( k' c C s ) > 1, Fz r. tr S i4 it C. f("- <br />. _ <br />o,ti w. It, ►�ttSl £ Hd <br />dei 3330 A4 Ak4- Con r_� -LoP . <br />� c[tp S�Gu <br />1/18/2000 <br />