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WELL PERMIT APPLICATION FORM UNIT IV <br />'y TRECEIV SEVICS <br />�ENVIRONM ENTAL HEALTHB D IVISONT` PHSREHDE) <br />DEC 2 g 1999 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ORIGINAL <br />ENVIRONMEN IAL HEALTH <br />(209) 468-3450 <br />PERMIT / SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or 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 />Ca.-n+T,y CIV6 6JUL. Assessor's <br />WElw Location J'65(o ou,4r�! �, IN.a 131vQ Cross Street Mi��Y� R.Ao City S -7-K i on_Zip Asa 01Parcel# <br />PROPERTY Owner T' H 1 2� L 0,z(_Address y 2_0 W • yoSem!}E 6veCity M4rj7eKC, Zip3c,'5(Phone# ZC�-6Z3-7o� 3 <br />� 2o" <br />l ��-oCC �r�Zp qszLim 0 -CV <br />C-57 Contractor A, -JC eb �nv,i1�pAd)ess 7 p L)1Sot n� <br />1nEnyAddress 51*,e CG�L&yQ ('Lie,G26-1 3 Phone# <br />-maSubContractor Mi+clQI1 Dr <br />•SIS Coordinates: X <br />Y <br />Township Range Section <br />I DATE <br />TO BE PERFORMED <br />5n <br />�I <br />`WORK <br />bYNEW WELL / BORING <br />( CPT. GEOPROBE, HYOROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION (choose type below) <br />N-1 <br />0 SOIL BORING T <br />0 OVER -BORE <br />QN <br />0 WELL # M I 1 <br />AA ^' _ 2-!v1_ w,_. ,��-.�J 0 PRESSURE GROUT <br />C_ <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MULTIPLE CASINGS? 0 YES WELL CASING DIA: 1',Y <br />MONITORING <br />OLLOW S i M <br />DIA. OF BOREHOLE'6-;e,01 'T�46 <br />'PVC OTHER: <br />JEXTRACTION <br />AIR HAMMER/DRIVEN <br />CASING THICKNESS 0,1.. .. TYPE OF CASING: 0 STEEL` 0 <br />VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL -I TREMIE TYPE TO BE US�EDD...k AUGERS CHOSE <br />D AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes �No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />0 SOIL BORING <br />Q HAND AUGER <br />APPROX. BORING DEPTH a . Fo i LTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />CONDUCTOR CASING PROPOSED1 (if ES, fist specifications here): <br />COMMENTS: <br />OACHMENT PERMITS] <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR <br />hereby certify that I have prepared this application and that the worx will be done in accoreance with aan ,loaquin �_vumy viwi�mi�c�. ��a.� •� • •�•�- <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />`or which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />:ontracting signature certifies the following: 'f certify that in the performance of the work for wnicn this permit is issued. I snail employ persons subject to <br />✓VORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVAN OR ALL REQUIRED INSPECTIONS. C <br />Signed x <br />Title ' T o .Date /Z — Z o <br />SEE SITE MA N UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Aovlication Accepted By <br />Date Issued Area <br />Grout Inspection By Date Final Inspection By iy Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />EJ <br />i <br />PE CODES I FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH RECEIVED BY <br />I DATE <br />i <br />ST NUMBER I INVOICE <br />5n <br />�I <br />1 1 <br />z I S RR# DD S I <br />UNIT IV - 5/99 /MI <br />