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a e ssued 7 1 2- - Area 0 7 SI, <br /> <br />Date 2-I/a° <br />Date <br />Final Inspection By <br /> <br />Date <br /> <br />WELL PEMAIT APPLICATION FORP UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 juL 1 0 2.000 <br />(209) 468-3449 <br />WELL Location <br />PROPERTY Owner 1U ddress 5 211 Ptifvfv- 51— City i-t)A Zipq./2*-Phone#L;g 3 —to(oo <br />C-57 Contractor ‘1/1101 HAL-1/(W- Addres32-33 61-2-yakt.- City Zip '9 1L12tic#1-19Phone0/ COL3F 7Z-:76 <br />Consultant / Sub Contractor A-1/100.1)-- 'Gk.) rikAtl dress 1:41) 144,tffiay 454:76e&ic#ab07--3Phonif79 4(07- <br />GIS Coordinates: X <br /> <br />, Township <br /> <br />Range Section <br /> <br />VRONMNI0\ iHiEr.PAM NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN000017SEIA y <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application istnigde 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 />41 Cross Street / 1-6- itz 41/aity 5-izAA zip ,?-5-5 Parcel# <br />Assessor's <br />WORK TO BE PERFORMED <br />2 ._EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />9 SOIL BORING # <br />II WELL #/--C <br />4 ,5 ae- <br />COMMENTS: <br />'Other: <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />,_ONITORINGAHOLLOW STEM <br />0 EXTRACTION WIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 9 PUSH POINT <br />9 SOIL BORING 9 HAND AUGER <br />OTHER: 9 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE O F( MULTIPLE CASINGS? 9 YES 0 WELL CASING DIA <br />CASING <br />- <br />CASING THICKNESS TYPE OF CASING: 9 STEEL„....0-PVC 0 OTHER: <br />DEPTH OF GROUT SEAL /6 ?WA-- TREMIE TYPE TO BE USED: 9 AUGERS ['HOSE <br />GROUT SEAL PUMPED: 9 Yes ArF/o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br />APPROX. BORING DEPTH le Fae,11-- BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> <br />veils <br /> <br />COMMENTS: <br /> <br />NOTE: OFFSITE 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: "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 />CALL TH - UNIT IV INSPECTOR 48 WORKING HRS IN ADV NCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x a1944--C) <br />Alai <br />Title/Company ez.. i% '4 PAO <br />Print Name <br /> <br />Date <br />WORK PLAN DATED:(5 -'U1 <br />EPARTMENT USE ONLY <br /> <br />SEE SITE MAP IN UNIT <br /> <br />Application Accepted By a 4.1.-0--e C' <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONSf-- /C 5 p <br />ACCOUNTING ONLY: AID# EAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />-- OZ 17 ce:, -7/rai,,e, sR# 3 -3 7 S.- <br />1/18/2000