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<br />TYPE OF WELL CONSTRUCTION TYPE <br /> <br />ONITORING HOLLOW STEM <br /> <br />EXTRACTION I 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br /> <br />3 AIR SPARGE 0 PUSH POINT <br /> <br />SOIL BORING 0 HAND AUGER <br />3 OTHER: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />WELL PERMIT APPLICATION ARM UNIT IV <br />REC IriV <br />NOV 0 5 1999 <br />OAQUIN COUNTY PUBLIC HEALTH SERVICES <br />IRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />PERMIT / SERVICES FkON-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 />zipg.s37 4 PA.sa sesiosorLe9.10 JA„ <br />mp.1576phonecg.i..;---‘4.5r- <br />cat22hone# g67 AO 6 <br />,,,t5s76'? Phccile3r47--7274 <br />ENVIRONMENTAL. HEALT <br />WELL 1-!ocitiori::"4 41°57E- Cross Street A144- 6CitY <br />PROPERTY Owner ibe.- -"a5rt Address2 4/8zb <br />4-elarivtiviAroehire? 1406— id GO/754d city_<74EX12/131‘i 0-57 Contractor <br />Consultant / Sub Contractor g57--- /144,7L-- Address-33:.D 1-1 (-7 4Z-City <br />GIS Coordinates: X Y Township Range ection <br />aOr <br />WORK TO BE PERFORMED <br />..)ic NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER) <br />SOIL BORING 0 <br />cVELL# t <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />(j)( <br />DIA. OF BOREHOLE /11 14 MULTIPLE CASINGS?,KES 0 NO WELL CASING DIA: \A) <br />CASING THICKNESS 2,1( TYPE OF CASING: 0 STEEL {31\--/C 0 OTHER: <br />DEPTH OF GROUT SEAL \te..S- 1 TREMIE TYPE TO BE USED:,ArkUGERS °HOSE • <br />GROUT SEAL PUMPED: elpf-es No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH . (E)43.6-LTED TRAFFIC BOX or STOVE PIPE V\ t <br />CONDUCTOR CASING PROPOSED? (it YES, list specifications here): <br />'Other <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS1 <br />I nereby 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 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: 'I 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 /> <br />Title i Q <br />- 9/ <br />--27C9 7 1( S Date <br /> <br />ome?1, <br /> <br />Signed x <br /> <br />SEE SITE SITE MAP IN UNIT IV WORK PLAN. DATED <br />/Vov/ Area 353 <br />Date <br />ACCOUNTING ONLY: I AID# <br />FAC0 <br />PE CODES FEE INFO AMOUNT REMITTED CHECKIVCASH I RECEIVED BY ST NUMBER <br />I INVOICE 1 , DATE I PE • <br />-35-b/ I Iqc(,00 I 11 .6 Sii, '' 2-10 Ci', "- <br />Date Issued <br />Date /(L'-/ Final Inspection By <br />1 I <br />Date <br />PARTMENT USE ONLY <br />UNIT IV - 5/99 /MI