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ORIGINAL <br />10tEllV <br />N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAY 0 52(100 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENViRONiVIENT HEAL 13P 4 TT -.304 E. Weber, Third Floor, Stockton, CA., 95202 AL <br />PERMIT/SERVICES (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 />--nichk.S c/-Cross Street City t <br />izal (4_ zip,/52t) PAasrsceesiltsor's <br />Address 12 6 6)( ie.5 4./ City FM-Zy ZiMlia;Phone#30 dieo <br />C-57 Contractor Oi51711:11- <br />GIS Coordinates: X Y Township <br /> <br />Range Section <br /> <br />_WELL PERMIT APPLICATION FORM UNIT IV <br />WELL Location Location <br />PROPERTY Owner 24fA 5Yki <br />Consultant / Sub Contractor/46) <br />Address .;23315-riy1-teii (X.- City„c7‘AZip6/5-1 7y1c#5j1 / hone# 1/114-3 e - 72X, Periz:L4 - • c- <br />Address44)6 /kfan4tik))&•Ukity SheeeflIkiit# Phone# &IV ./ /60 <br />WORK TO BE PERFORMED <br />MEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />OIL BORING # <br />*Other: <br />COMMENTS: <br />Lae,. <br />0/DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT ,r,ELL# <br />TYPE OF WELL INSTALLATION TYPE <br />ffiONITORING SIOLLOW STEM <br />O EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />O SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE " MULTIPLE CASINGS? 0 YES ,F7NO WELL CASING DIA: 4— <br />CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes $1Clo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 150 fee'r 60LTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />MiA LzA/ <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: "I 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: "I 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 />9A_LL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x 4L4 Title/Company Igel— <br />Print Name W1 /I'-t. Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 12'Y- <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By <br />Destruction Inspection By <br />COMMENTS / COND NS: <br />ACCOUNTING ONLY: <br />w <br />AID# <br />iii <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PR71T1TSERVICE REQU <br />I -11AAJ / ,61 22__. eitA, c_.5.co <br />00 2 20 ( <br />Application Accepted By <br />Grout Inspection By Date <br />Date <br />?•• Area sev <br />1/