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Grout Inspection By Date <br />Destruction inspection By <br />COMMENTS I CONDITIONS: <br />Final Inspection By <br />Data <br />u Lb/ ZULIU 26J4t3t1.:14z;.:l F-11-11-i FLOUR <br />WELL PERMIT APPLICATION FORM <br />OIN f'fb <br />UNIT P_Ld_ 01\1 <br />SAN JoAQUIN COUNTY PUBLIC HEALTH sERVIcW jr_r!_ I pt <br />ENVIRONMENTAL HEALTH DIVISION (PHs-EHD) I 1. 14 9 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <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 descried. 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 Loc.stion2.15‘q 5. Cross Street City 12o.ve.e.1343k. zip 9536,-7 Parcel# 2 q 9 - 0 7 0.- 0 i 2- <br />PROPERTY Owner 1)k-;-, k \ '''‘ /W - Address 617 0*Fain-e/ S-freel $0 cityStui E-4.c.:1 L6, —JZiP Clq 16 9 PhOne#96 1HO -20 '-i 7 <br />C-57 Contractor Wesk 1Auzwiai Address13 233 12-z-li pi City Row.14.-6-,J,-,..,.: Zip 95 7 412 Li c# 65 den 97 Phone#414- b3(3- 7274- <br />Consultant 1 Sub Contractor 5 e co 2- -.1.4q_iceAck k Zum 41/4 Address 30 il ictbove V. c..,-.1-e la.) CItyRaw.110(4-41/.4c,Llcit 6,162- Prione#% %I- OV00 <br />GIS Coordinates: X Y , Township 3 So,A-\-‘ Range 41 EAC <br />WORK TO BE PERFORMED <br />Section Z <br />INEW WELL S BORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />RiSOIL BORING # _ <br />W1ArELL #_ 44 W - <br /> <br />13 DESTRUCTION (choose type below) <br />U OVER-BORE <br />fl PRESSURE GROUT <br />LA <br />*Other , <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />"MONITORING If/HOLLOW STEM <br />1:1 EXTRACTION AIR HAMMER/DRIVEN <br />0 VAPOR a MUD ROTARY <br />El AIR SPARGE D PUSH POINT <br />a SOIL BORING fi HAND AUGER <br />OTHER: flOThER <br />CONSTRUCTION SPECIFICATIONS r! <br />CIA, OF BOREHOLE g" MULTIPLE CASINGS? fi YES eN0 WELL CASING CIA: 4 <br />CASING THICKNESS San LI 0 TYPE OF CASING: a STEEL irt"VC )1 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: iAUGERS [NOSE <br />GROUT SEAL PUMPED: a Yes a (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH '-jO a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />COMMENTS: 75 CI,- \-ke--‘ vo,-•-iciA <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: -1 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 tiler 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 />wp00:61011tit;IN .ADVANCEI.FORALt4REO U I REDANSPEOVIONS <br />Signed x Title/company secotz_ 4,1-1 <br /> <br />Print Name -S-cgI 214.1 c, Atiutoev Date 7- 1 - <br />DEPARTMENT USE ONLY <br />Application Accepted By Daze Issued 7—/ 3 -oo Area OIR51, <br />ACCOUNTING ONLY: AID# F.A..cdt <br />PE CODES FEE INFO AMOUNT REMITTED CHECK It REC'D BY DATE NVOICE - --. • " 'T- 0 1 3- <br />350 k i Ok 2•2:4- AkAd 1 I • IV 00 2-33?3 <br />1/18/2000 <br />(eD