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WELL PERMIT APPLICATION 1-ORM <br />On • u <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 />Assessors , v • <br />WELL Location :1-• LI 6 I V- \Ali lio Cross Street i‘ ci 14 it 5'16(14 )011 zip q ;.0 3 parcel# , 1-0 7 -1 <br />PROPERTY Owner 1r)1:6 r <br />e <br />0-57 Contractor hd '04 ("c -II V iircovY 'A dress -100 5- V 1g, (Soo tect \/ City S 14 A/ Zip)-0 Lic# 6O,27 Phone# Lt6"/ HOC 6 <br />Consultant / Sub Contractor Address City U Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />9 NEW WELL I BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER") <br />a SOIL BORING # <br />9 WELL # <br />DESTRUCTION (choose type below; _x, <br />0 OVER-BORE <br />9 PRESSURE GROUT <br />'Other: <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />9 MONITORING 9 HOLLOW STEM DIA. OF BOREHOLE ; ' MULTIPLE CASINGS? 9 YES 0 NO WELL CASING DIA: t•-----"' ___ <br />9 EXTRACTION 9 AIR 1-LAMMER/DRIVF_N CASING THICKNESS IV/ /1 TYPE OF CASING: 9 STEEL 9 PVC D OTHER: <br /> -. <br /> <br />9 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1' -P TREM1E TYPE TO BE USED: 9 AUGERS BHCSE r— <br />] AIR SPARGE 2 PUSH POINT GROUT SEAL PUMPED: a Yes i g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />,3,SOIL BORING 9 HAND AUGER APPROX. BORING DEPTH -30' 0 BOLTED TRAFFIC BOX or 9 STOVE PIPE V-') <br />9 OTHER: CONDUCTOR CASING PROPOSED? (it YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS1 <br />nereby certify that I have prepared this application aria that the won< will be oone in accorcance with San Joaquin County Ordinances, State Laws, and Rules <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 />for which this permit is issued. I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x /.7141.94)-uv1 Title ?ro cl G c.)101) T Date <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />04 7,99 <br />Address 1 / 5- ( /LI I FI vc1 City r vov.c1 0 Lpq ‘;-3 Phone# '30 "(, LI 971 <br />/ <br />SEE SITE MAP IN UNIT <br />Application Accepted By <br />Grout Inspection By <br />Destruction InsPection By <br />IV WORK PLAN. DATED <br />tt) Date Issued <br />DEpAIRTMENT USE ONLY <br />4v, Date Final Inspection By <br />Date <br />Area 3 <br /> <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br /> <br />PE CODES FEE INFO AMOUNT REMITTED CHECKVCASH 1 RECEIV D . DATE P - • SERVICE REQUES i"NUMEiR INVOICE <br />R((_ cc tz5744 ,,,,W 410 i sR#0 ac St <br />UNIT IV - 5/99 /MI