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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 WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the fonowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />HE A LICANT HRS IN ADVANCE FOR ALL EQUIRED INSPECTIO S. <br />Title fr-QS,c/e4 Date '2-0 0 <br />SEE SITE MAP IN UNIT V WORK PLAN. DATED 913191 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> <br />DEPARTMENT USE ONLY <br />Date Issued <br /> <br />9// <br />lc/ 2- ?—(t7, <br /> <br />Area <br />/4/X4-4 <br /> <br />Date I 01 Z. 210 2- Final Inspection By <br />Date <br /> <br />Signed x <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 />Assessors <br />WELL Location 50 C S AlReeRt WAY Cross Street L.E• OixoN S (City StO C. roN Zip 2 0 ki Parcel# <br />PROPERTY Owner 10C-ts ro t4 MrRo AIRPORPkddress 5000 5:MIRPCHr WI City 5 TO C I' IC V Zip 9S2.01i Phone# (20 9 ) 46e-410e <br />C-57 Contractor k i tcii ELL o1ill111 G-Address I CC I IvIll AT I 0 VA `f City RA liC It° Zip %6'1-0 Lic# 02(111 Phone# (910 “1" 3 5? 3 <br />Ce.,ROCJA <br />Consultant/Sub Contractor CA AM AC-E NV Address P: O, 8 C X ei;? City IkAarli ACttrC Lic# g- e 5 G Phone# OIL) 3 S4 -3 1" mti <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER.) <br />0 SOIL BORING # <br />(3) IWELL# MW-Z Mw-3 <br />*Other: ' <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />I MONITORING I HOLLOW STEM DIA. OF BOREHOLE IN MULTIPLE CASINGS? a YES I NO WELL CASING DIA 21W <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S'L it 40 TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4-L) - F TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br />0 AIR SPARGE 0 PUSH POINT <br /> GROUT SEAL PUMPED: I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING 0 HAND AUGER <br /> APPROX. BORING DEPTH I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? 1,4 Q ( if YES, list specifications here) gNni 4-}061 .1,, V 0005 COMMENTS: kfadc f t(Cw%. or-oa-e../ ce.e •i9q <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKNCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 s-ol 49,00 a9 ciLi K <br />UNIT IV - 6/1/99 /sign bkpg/MI