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Grout Inspection By <br />Destruction Inspection By b' <br />COMMENTS / CONDITIONS: <br />FEE INFO PE CODES <br />ACCOUNTING ONLY Al D# <br />AMOUNT REMITTED <br />got .00 <br />CHECK # PERMIT I SERVTCE-RECILI VOICE <br />SRt 0023 I 5,e) <br />JUR1-1-12-000 <br />1/18/2000 <br />WELL r)ERMIT APPLICATION F. ,,ZM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC JEC_EYED <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JUN 1 6 2000 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ENVIRONMENT HEALTH <br />PERMIT/SERVICES <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 /5-66S-15-77.c:/AlfigaL, XI Cross Street 16 i'6 f/-w- city -L..V.41f -enf Zip Parcel# <br />PROPERTY Owner A-z.z.----Af &972A/ Address /s-4666,7'Alicri5WaL kt City /%5c4-c_cui Zip Phone# <br />C-57 Contractor /47:44,..0,-0-Jc. ..art-i4e-w.4.44- Address yin Ai...,, 4.1. City ....$)C.4t-1Zdi Zip1.5.`14 Lic# Phone# <br />Address ,O= 450X ‘71-1 Phone# zo? sfrs,--09.0 Consultant/ Sub Contractor Z .L.Acitri .ii,JC, CityC14410/116: Lic# <br />GIS Coordinates: X Y Township 715- Range ,e9C- Section fik) ti 24 <br />WORK TO BE PERFORMED <br />StIEVV WELL / BORINGr( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />Olt/ELL # / <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />'Other- <br /> <br />COMMENTS <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />,EVONITORING r 0LLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR U MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE8 " MULTIPLE CASINGS? [I YES 21O WELL CASING DIA: <br />CASING THICKNESS Sidi 41a TYPE OF CASING: 0 STEEL /KC:NC 0 OTHER: <br />DEPTH OF GROUT SEAL 7040 ( TREMIE TYPE TO BE USED: 0 AUGERS 5KIOS - <br />GROUT SEAL PUMPED: Al'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3 <br />APPROX. BORING DEPTH 2 90 .4:5 r 0 BOLTED TRAFFIC BOX or Tie..5TOVE PIPE r CONDUCTOR CASING PROPOSED? PO ( if YES, list specifications here): <br />COMMENTS: <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." <br />Contractor's hiring or sub- <br />contracting signature certifies the following: I <br />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 />C LL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x ik.) Title/Company /2/47 /424eni'f-fife-s tdifi-14.,kiirf <br />Print Name Name At4 /-1, /6,C 4r- Date 4 '/ tit' <br /> <br />SEE SITE MAP IN UNIT IV WPF.ZK ..FLAN, Dpjp:, <br />/ ( ,c. viDOEPARTMENT USE ONLY (-) j .„, ..„., <br />Application Accepted By <br />Date Issued (.44%-(._ C_ I /6.vvi../ Area <br />Date 5fraFinal Inspection By Date <br />Date