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NON-REFUNDABLE PERMIT F_XPIRE9' YEAR FROM DATE ISSUED <br />Appiicaticn is hereby made :C Saa _ ,3qu:^ County for a cerrvt to constn:cV, and/or install the wort descriced -his aopliczlion s mace cr, conalianc. H:r- <br />San Joaquin County DevPlopmenc ':Me Chap'et S•t 115.3 and the Sta'idards of San Joaawn Co inty ?ubiic Health Servrxs. Er.v ronnental Heal'h Division <br />W 11th Street Chrisman R Trac 95376 Assessors N/A <br />WE'LL Location C:.ss Street Itt�/ _ y Z;a Parcel+i <br />PROPERTY OwnerSan Joaquin County AddressCity Zio Phone# <br />Spectrum Exploration <br />C-57Crntrctor Address 2365 Wigwam 1465-8712The San Joaquin Company ^ 8617 Etcheverry City Tracy Phone�209) 832-2910 <br />Consultant: Sub Contractor ddr=ss -- ' <br />GIS C'�ord.natss: X Y Townsnio Range Secticr n <br />WORK TO BE PERFORMEC v <br />V EIJ WELL i BCRING ( GPT, r O�RCBE. HYDROPUNCH. HAND -AUGER. OTHER') 0 DESTRUCTION !choose ype oeiowi <br />OPT. <br />BORING # a-aCOPE <br />VWELL+M___ GE:SURc GROUT <br />'Other: <br />COMMENTS See Attached <br />- e <br />0ONITORING <br />2 HOLLOW STEM <br />z <br />� <br />0 AIR HA.MMER/DRIVEN <br />cs•• <br />0 MUD ROTAFY <br />0 AIR SPARGE <br />'eUSH POINT <br />�f;IL BORING. <br />Q HAND AUGER <br />y Uj <br />3 OTHER <br />vLU <br />A'�4YYI <br />.t <br />v� <br />— <br />WELL PERMIT APPLICATION FORM UNIT Iv <br />R <br />; I^ <br />_: <br />SAN JOAQUIN C04JNTY PUBLIC HEALTH SERVICES <br />�,,,U'� <br />Er « <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHC) <br />> CL <br />304 E. Weber, Third Floors Stockton, CA., 95202 <br />- <br />W <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT F_XPIRE9' YEAR FROM DATE ISSUED <br />Appiicaticn is hereby made :C Saa _ ,3qu:^ County for a cerrvt to constn:cV, and/or install the wort descriced -his aopliczlion s mace cr, conalianc. H:r- <br />San Joaquin County DevPlopmenc ':Me Chap'et S•t 115.3 and the Sta'idards of San Joaawn Co inty ?ubiic Health Servrxs. Er.v ronnental Heal'h Division <br />W 11th Street Chrisman R Trac 95376 Assessors N/A <br />WE'LL Location C:.ss Street Itt�/ _ y Z;a Parcel+i <br />PROPERTY OwnerSan Joaquin County AddressCity Zio Phone# <br />Spectrum Exploration <br />C-57Crntrctor Address 2365 Wigwam 1465-8712The San Joaquin Company ^ 8617 Etcheverry City Tracy Phone�209) 832-2910 <br />Consultant: Sub Contractor ddr=ss -- ' <br />GIS C'�ord.natss: X Y Townsnio Range Secticr n <br />WORK TO BE PERFORMEC v <br />V EIJ WELL i BCRING ( GPT, r O�RCBE. HYDROPUNCH. HAND -AUGER. OTHER') 0 DESTRUCTION !choose ype oeiowi <br />OPT. <br />BORING # a-aCOPE <br />VWELL+M___ GE:SURc GROUT <br />'Other: <br />COMMENTS See Attached <br />- e <br />0ONITORING <br />2 HOLLOW STEM <br />0 SXTRACTION <br />0 AIR HA.MMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTAFY <br />0 AIR SPARGE <br />'eUSH POINT <br />�f;IL BORING. <br />Q HAND AUGER <br />OTHER. <br />3 OTHER <br />CCNSTRUCTION SPECIFICATION \� <br />DLA. 17F i3ORE`iOLE 6" MULTIPLE CASINGS? 0 YES <br />Q'�VO f�E_L CASING DIA2" <br />CAS!NG 7H1C'KNESS S ch 40 TYPE OF CASING: 0 STEEL OVC 0OTHER: <br />DEPTH OF GROUT SEAL__LL r 'REIAIE YPE TO BE USED: Q AUGERS t%IJSE <br />GROUT SEAL PUMPED: ees p No ( NOTE: MAXIMUM FREE -FALL DEPTH IS n.) I <br />APPRCX. BORING DEP7-1 21' g40LTED TRP.FF:C BOX or p .TO VE PIPE <br />CONDLCTOR CASING PROPOSED? No ( 'f YES Pst soecificarior.s r.ere1: _ __ <br />conrMENTs: <br />See attached Figure 11 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENGMUAL.rin r-fM I rt=ttml I J <br />1 hereby Canty that I have prepares this aopucatien anc trap the work wi;l to :one in act: mance wri Sen . oaautn County Orainancas. State Laws, ani Ru:as <br />and Regulations of the San Joaquin County. Homeowr er or ; censed agen•'e signature Cenl ies the 'ollowing' 111 certify that in the performer, ce of the .vcrk <br />for which this permit is issued. 1 steal! not employpersons subject to WORKERS' COMPENSAT70N Laws of Calffornia.'• t'ontracto' S hiring or V-'t- <br />ccntracting signature certities t -1e `o!lowing: "l terrify tsar in ch9 ce.fornance of the .York 'or v.hich this Permit is issued. i shalt srrrrc•y persons subivc- to <br />WORKERS' COMPENSAT1CN Laws of California.' <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />l'T , TItie Consultant D,!, 3/23/00 <br />jiyn9d X � <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />AppiicaC.o- .Acceptea9y _Date 'ssued <br />Gout Inspection ByJ Dated 'Z --id inal Inspection By Date_ _ <br />Destruction irsoaccion By Data <br />COMMENTS I CONDITIONS: --__— <br />ACCOUNTING ONLY: ; AICA <br />=E::ODES I PEE INFO AMOUNT REMITTED CHECK p i REC-0 BY i DATE <br />OI <br />WE <br />C-37 LIC-ZI14SED CUNTKXCTOR V;LST SIGN'LICENSE SCWOKKF.RS' <br />UNIT V4 - 6/23r4o /sicn bkoriML <br />1 PERmMI` ii sEERR <br />CRt' 3! O 0 <br />INVOICE <br />R.iTI01IN <br />