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COMMENTS / CONDITIONS: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection <br />Mai* <br />WELOPIERMIT APPLICATION RJRIVI <br /> <br /> <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 APR 14 2000 <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 /> <br />, 0 pAasrscees; o r s <br />WELL Location S3DO (4Ml4,-/ glvol Cross Street .Slcanit r A-ve... City 5+-oc 3 <br />1 <br />-Or Zip -I <br />PROPERTY Owner Q•en _Co Aen Lv /-, Address WOO ), Lt)cpd-ri LA, 814 City c} kJ in Zip °/phone <br />C-57 Contractor Yi Nctte.(1 I) I in.) Address c-36 o 4,, (AM- AUC, City Sc/CfootAen'bZiOCYX Lic# C-7,26/7 Phone#(q16) •1/6(.0 <br />Consultant / Sub Contractor Pc-C1 L" Address (1065— /11, LA-..b City SI-oCh /vet Lic# Phone0 t/67-/011. <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />KEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />Er WELL # MIN 3 /114.,14 <br />*Other: <br />COMMENTS: <br />4:4313 <br />fl DESTRUCTION (choose type below) <br />O OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />VAONITORING A(HOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />COMMENTS: <br />(2.) <br />CONSTRUCTION SPECIFICATIONS , l <br />CASING THICKNESS AA-- TYPE OF CASING: a STEEL ''PVC 0 OTHER: <br />DIA. OF BOREHOLE g )' MULTIPLE CASINGS? 0 YES >KNO WELL CASING DIA: 0J <br /> L.i.. <br />DEPTH OF GROUT SEAL En-I--; r C TREMIE TYPE TO BE USED: 1KAUGERS ['HOSE <br />GROUT SEAL PUMPED: p Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH D 5 ' A'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NA- ( if YES, list specifications here): <br />0 <br />NOTE: OFFSITE 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, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's 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 />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />iii2/141\n, <br /> Title <br />/?;(/e 2006 Area Kr6 <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE /1:-U2171TTSER‘tfeE-REQUEST # INVOICE <br />g9,00 (3s--70 j-7 7,1),,, ----c ) krillti,o\sR#o02z4 A <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />C-57 LICENSED CONTRACTOR MUST SIGN LI NS WORKERS' COMPENSATION CLARATION <br />Signed x Date <br />Dat <br />Date <br />EPARTMENT USE ONLY <br />Clte Issued <br />'186Vinal Inspection y