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Title/Company /98 /4-6 ..c.-iiir-,7,-..4--, <br /> OM Q -3 -00 <br />AOL4W -....U. 1,7',:::.;Ly OIjç LW•L‘bAtt <br />DEPARTMENT USE ONLY <br />Date Issued 1) r \ k - lig? Area <br />Date In -1141) Final inspection By Date <br />Date <br />Signed x <br />Application Accepted Accepted Sy <br />Grout Inspection By <br />Destruction Inspection By <br />Print Name <br />A <br />Received Mar-03-00 12:59pm from CCITT G3 -) AQUA r ENCE <br />3-02-2000 1 :22PM <br />page 2 <br />P_ 2 <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 96202 <br />(209) 468-3449 <br />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 />Assessor's <br />WELL Location 4,14 , Cross Street A'rp-iij - City r70.11-a-.4-4._ Zip .7533 Parcel# <br />PROPERTY Owner F-• n 'irks_ Address 30.5 A) • City /90,1i-'-d-c-c. Zip Y.575? Phone# 7-0 9- 4:-/ 35z/ <br />C-57 Contractor 6I-9.5 pr.- II/ ns Address 95c1 Rd City "2"1-,;14-- Zip7 53 uo 15,5/4.5-ph ono 2-z-5 - 3/3 -5re e <br />Consultant/Sub Contractor E.15 Address 1-) bi Rirh,de City a/r)d.lirt._ tic* ilicroPhont# 925-520 23 i/" <br />GIs coordinates: X <br /> <br /> Township Range Section <br /> <br />WORK TO SE PERFORMED <br />IP•IEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION {choose type below) <br />0 SOIL CORING ft 0 OVER-BORE <br />0 WELL # 0 PRESSURE GROUT <br />*Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING NiOLLOW STEM <br /> <br />CIA. OF BOREHOLE SI MULTIPLE CASINGS? 0 YES *NO WELL CASING DIA: "7-• <br />O EXTRACTION Q AIR HAMMER/DRIVEN CAStNG THICKNESS 5cA-- YO TYPE OF CASING: u STEEL fk:Pvc u OTHER; <br />0 VAPOR UMUD ROTARY <br /> <br />DEPTH OF GROUT SEAL 6f TREMIE TYPE TO BE USED; 0 AUGERS POSE <br />AIR SPARGE fl PUSH POINT <br /> <br />GROUT SEAL PUMPED: (1 Yes fieflo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br /> <br />APPROX. BORING DEPTH /, &BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />BOTHER: OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here); <br />COMMENTS: <br />NOTE: OFFS1TE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I 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 agent's signature certifies the following; "/ certify that in the performance of the work <br />for which this permit is issued, ishali not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's 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 stIbleCt to <br />WORKERS' COMPENSATION LawS Of California." <br />CALL THE'UNIT'IV INSPECTOR 48 WORKING HRS IN AbVANCE'FOR ALL REQUIRED INSPECTIONS. <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY AID# <br />FAr# <br />FE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - - • • .- T ti INVOICE <br />% • . 2-01 16 <br />AY.,"