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FAratk ACCOUNTING ONLY: AIDS <br />1/18/2000 <br />/24,..,csy-e.- v60 d-tr <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 Regulatons of the San Joaquin County. Homeowner or lIcenaed agent's signature certifies the following: '1 certify that in the performance of the work <br />for which this permit Is i.ssued, I shall not employ persons sullject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "I certify chef In the performance of the work for which this permit is issued. I shell employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />.CALti'.T.14514MIVI ...StOt:cOR 4 7r'81N.P:EZKI:NIOUltWIN'ADVANCEIF!DRALLittEQ,U.IRED 3NgPEt.(0.WS <br />..„.„, . . . ,.....,. <br />Title/Company <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Final Inspection By <br />Signed x <br />Print Name e----7/-e- ;c/7;7i447-=/ZA----S Date ./6 <br />. e <br />Date <br />Date <br />PE CODES <br />?5.5L NA) fee0/007 to/2.- Ca=6t, <br />REQUEST <br />tv.2o,240._?-o <br />VOICE ___ FEE INFO AMOUNT REMITTED . CHECK # <br />DEPARTMENT USE ONLY <br />Date Issued <br />04/28/2000 0B:23 2094683433 FIFTH FLOOR <br />PA ORIGINAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <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 <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 /71/ t. /1;25791 /fre, Cross Street #14/r V City 1 4WrEtfi Zip Parcel# .-goe 3/0 I 2_ <br />PROPERTY Owner/4-t-LAT-111‘. giscri- al,Acklress PD. 13'ox 65id city t1006A Zip (i`i'VC P h o n e# <br />C-67 Contractor 11,06T titZiktfir _AddresSiS25 reT745rEfehi. p CitYPjfitalit ZIP Y571e Licit Phone# <br />Consultant / Sub Contract° 5 3iN7 Kii-421)1ZE tr-4 city ec.ekvvimdt pri„eli('4a1V-0 120 0„tti 4.etriCIRP, <br />GIS Coordinates: X <br /> <br />Township Range Section <br /> <br />.JL All <br />WORK TO BE PERFORMED <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER OTHER') <br />SOIL BORING # <br />WELL # -rugottyit n4 kv— I 0 <br />COMMENTS: <br />'Other. <br />O DESTRUCTION (choose type below) <br />U OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING )(HOLLOW STEM <br />0 EXTRACTION C AIR HAMMER/DRIVEN <br />a VAPOR a MUD ROTARY <br />n AIR SPARGE D PUSH POINT <br />a SOIL BORING U HAND AUGER <br />0 OTHER:C OThIER <br />CONSTRUCTION SPECIFICATIONS <br />CIA, OF BOREHOLE ./(. // MULTIPLE CASINGS? 0 YES NO WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC a OTHER: <br />DEPTH OF GROUT SEAL____. TREMIE TYPE TO BE USED: 0 AUGERS [NOSE <br />GROUT SEAL PUMPED: U Yes XNazi_110TE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH )(BOLTED TRAFFIC BOX or I} STOVE PIPE <br />CONDUCTOR CASING PROPOSED? <br />VII <br /> <br />r( If YES, list specifications here);