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II;''22/2F C0 II: 3:: 2094693433 FIFTH FLOOR F,I;E <br />WELL PERMIT APPLICATION FORM SITE <br />SACS JOAf. UIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) UNIT IV <br />304 E, Weber, Third Fluor, Stockton, CA., 95202 ---------------_-- <br />(209) 4683449 <br />NON-REFUNDABLE PERMIT EXPIRES'. YEAR FROM DATE ISSUED <br />rApplic'aticn iis hereby made te. Sar, .ioaquin Courty fofor a osrT;t tp Cafi9tf< ar d wr irstali ,ire vrorK des;.nbad. + hiW spt;iicatiarl is made in camplia ice ,vith Sar <br />Joaquin County DevalapmQnt Tide, Chaptar 9-14'15.3 and the Stan7arCs of San Joaquin County Public Wealth Scwvlees, Envirxrnewai Health Division. �- <br />�1 r+5�t9L5Gr'b <br />WELL Locat9an. l/'_ c �.c t [ Class�Street ��—C Ity Zip��� 3G Pdreelst.--- — <br />FRCPLRTY �>wner �lA S i� Addrt Rs City y�?i� 1y Phone*_ F:�25•Zai <br />C•57 Contrartor_/- (,1)_0CkLy Add re <br />Consultant/Sub Gonvactor G,-C(a.Vt.z___ddress—a.AbX�Xl��(Gity��.i.* _PhonF#7� Si%8`lfl <br />GIS Coo,dlnates: x$ r � _--_ _, Township--_- Range <br />WORK TO BE PERFORINELI: <br />BORINC! � (,PT GEOPROE,E, H'YCr,0PUN0H, HAND -AUGER, CITHER-) U DESTRUCTION (*hoose type t'aw) <br />,a�SCIL ROR'NGt#, !b> b a ovER-SomR <br />_ f7 PRESSURE GROUT <br />—..— <br />00101vtEINTS: <br />ryP E OF WELL <br />INSTALL,ArION_ 1YRE <br />CONSTRUCTIQhI SPECIFICATION'S <br />Q P1cwT'oRm; <br />?,j HOLLOW STEM <br />DIA. OF BOREHOLE---K1kY. TIPLF CA8!NGG" DYES 9 NO WELL- CASING DIA: _ _— <br />!1 EXTP'AC":ON <br />Alfa. HA^A/°.aER/DRIVE:N <br />B'AS'ING THfCKNESS� TYPE Or' : AVNG: 0 STeFL r pvc n JTHER: <br />0 -,./AFGW, <br />MUD R TARY <br />DEPTH OF GROUT SEAL__-- HCSE <br />a AIR SPARr3F <br />(] PUSH POINT <br />GROUT SEAL. PUMPFD: a Yes tj l',,o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'} <br />Ir SOIL RG'R.iNG <br />0 HAND AUGER <br />3RgUTa'PECIFICAT;UNS:.----__--- ---- -- _-- <br />a OTHER: --�--� <br />OiF!ER.--__ . <br />APPIRCX. BORING DEPTH_ U BOLTED TRAFFIC 600 or a STOVE PIPE <br />CASIiNC P/ROPGSECII(if YESS,� Itst sP96 iutions here): — <br />100MI MENT54A.0 / [ tftl� <br />//CONDUCTO/R� r,, _ <br />��d-�.-� l� �` %� L _ <br />NOTE: OFFSITE SORINOS REQUIRE ACCESS OR ENCROACHMENT PERMITS. _ <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIR50 INSPECTIONS, <br />I hereby cert'Lfy that I have prepared this application and that the work vvill be dorse in accordance with Sari Joaquin <br />County Ord' r u and Regulations, and all applicable California State L'aasws;. <br />$lgnad x 7* _TitWC.ornpany 1?rr /` LJ� r *f,✓t r— a� 1 <br />print Name— tY i U` <br />DEPARTMEN I USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: G.�i._._— <br />WORK PLAN DA:T1El7 r/7—%26c70 <br />N 6V <br />Applictst on AOOF C Bv— Date,IssuQd /-----------AT e_-------.. <br />�, <br />� ut Inspect on BY..._...J...I -- Lllf`� 1 Da°e � 7iDi) Final inspect on BY --.-- —,- Cate <br />J"tructicr InsDectIon Ov v //// / I /,�Date <br />•--- —__-- _ — _ _ - T --------- — --- — --� <br />ACC.C:JNTINu ONLY: AtC <br />I FAL.'fl: l <br />FSE CCOES <br />FEE ihiFU <br />Al—Q-U-- iT REMITTEE) <br />CHECK # RECID BY i 0 E PE — EST F �iNVUiCE <br />C-3.1 __ WCC WAIVER___ C-57 Letter of Auth,o ixatl ra' siyrt I crrtit_ T ratrdcehment doc�� 9/2-7/00 <br />