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9-22-1999 A: OOPM FROM 1'. � <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br />�J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") o <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450`�'t7 <br />1 <br />5o NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O <br />Application is hereby made to San Joaquin County for a permit to construct and/or <br />install the work described. This application is oe in compliance with <br />e Standards ofSan Joaquin County Publics Health Services, Environmental Health Division. <br />San Joaquin County Development Title, Chapter 9-1115.3 and th <br />pAssessors <br />7 D ( <br />WELL Location DPMIdIWIIN F}oIr Cross Street _ ^city .51-oa w' zip <br />PROPERLY Owner 5 1 Parcel# ���'' - <br />7iL LT Address .0•$o 75)6 City-, oD [Z" Zip Phone# <br />� V _ <br />C-57 Contractor.Address <br />`I 5 0 M VIt RJ_ cityiMQ#ziPLicu Y$W4JPho,,11 1 5 13- SBOp <br />La <br />Address Bok A6, cih'�Licx Phone>*7a7-f3S-YSJ D <br />Consultant i Sub Contractor _La y1bi �l <br />GIS Coordinates: X • Y <br />WORK TO BE PERFORMED <br />Township Rang <br />NEW WELL I BORING ( CPT, GEOPR06E, HYOROPUNCH. HAND -AUGER, OTHER <br />Q SOIL BOA,` <br />n I L 50 <br />;WELL# . <br />'Other: <br />CG. MENTS' <br />TYpE OF yyELL % <br />CONS RUCTION Tl E <br />MONITORING <br />)(HOLLOW STEM <br />Q EXTRACTION � f�Y <br />Q AIR HAMMER/ORIVEN <br />A <br />f] VAPOR ( \,41A MUD ROTARY <br />Q AIR SPARGE <br />0 PUSH POINT <br />Q SOIL BORING <br />0 HAND AUGER <br />Q OTHER: <br />710 <br />Section <br />p DESTRUCTION (choose type below) <br />Q OVER -BORE <br />Q PRESSURE GROUT <br />CONSTRUCTI N SPEC FICA <br />DIA. OF BOREHOLE MULTIPLE CASINGS? Q YES NO WELL CASING DIA; <br />CASING THICKNESS i,4 yb TYPE OF CASING: Q STEEL XPVC Q OTHER: <br />DEPTH OF GROUT SEAL'S roYr1UrTREMIE TYPE TO BE USED: WAUGERSor ,)(NOSE <br />GROUT SEAL PUMPED: )(Yes p No (NOTE_ MAXIMUM FREE -FALL DEPTH IS 30'). <br />APPROX. BORING DEPTH 6S D I y BOLTED TRAFFIC BOX or Q STOVE PIPE =t- <br />CONDUCTOR CASING PROPOSED?VtPS—(ifYES, list specifications here):^(b $J IL] <br />1. I 1 rK) -12- e� L OM IJ C1w CCt6ly14 • �/S r� k1_ -� <br />COMMENTS: IJ <br />NOTE: OFFSITE BORINGS REQU E ACCESS OR ENC OACHMENT PERMITS! <br />l Hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agents signature ze �i`es'hG fcllc ; 9: "! corri fy that m the eerformance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hinng or sub- <br />contracting signature certiries the following: '1 certify that in the performance of the work for which this permit is issued. 1 sholl employ persons Subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />THE LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />3a i i��i'�r'/i -_Title% �riicd Ilii/�'� 'c36ate xr? Al <br />SEE SITE <br />MAP IN UNIT IV WORKPLAN DATED_ <br />DEPARTMENT USE ONLY <br />Date Issued `v Area <br />Application Accepted By DateA�6 <br />Date ,Final Inspection By <br />Grout Inspection By - - --- <br />�c_ i �e nn Rv Date <br />rnrtnn,�G'RtT.R ! (-r)NDITIONS: <br />ACCOUNTING ONLY: AID* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK91CASH <br />-, <br />t. is r <br />F <br />RECEIVED BY DATE �SR# <br />T/S EST NUMBER INVOICE <br />ni ;,J� 321,3' <br />