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" WELL CASING DIA: '2 4 4 , <br />THER: <br /> <br />WELL PERMIT APPLICATION Fat <br /> <br />1 UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />00 JLP <br />gNV_IRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Ikeb‘r, 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'sParceig et. 7_ 7 <br />WELL Location ?41 eF CM 41 5TP--ea ,Cross Street City SY0Celt2A) zip 57-100 <br />PROPERTY Owner kt CiAy dtoperty(o'gg:? (0' w. 'est cIA-7. sr: City -90(-41W Zip qc200 Phone# - 0302- <br />C-57 Contractor pi fimr-taNeiti2414ddress 53(00 5. Pra5; City SAc. zip 9525212 Lic#4,72- (W1Phone# _43.31&c/-4O <br />WitlucAll 2641 <br />sulY Sub Contractor 6c0g4/1/i Rt7,0%.4.4A1).rAk Address 4005/J 04 City 9/0c k Lic# Phone# /000 <br />GIS Coordinates: X Township Range Section <br />WORK TO BE PERFORMED <br />}KW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING4 <br />WVCELL # <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br /> <br />0 PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />ITORING efISLLOW STEM <br /> <br />XTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />1216—R SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />fl OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 54i0 MULTIPLE CASINGS? 0 YES 11440 <br />CASING THICKNESS StA -40 TYPE OF CASING: 0 STEEL <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: UGERS 01-10SE <br />GROUT SEAL PUMPED: 0 Yes U4 ( NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH-301 45'5W f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />) <br />CONDUCTOR CASING PROPOSED? N ( 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: "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 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 ME UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />Application Accepted Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIQNS: <br />o ci <br />ACCOUNTING ONLY: AID# FAC# <br />/ <br />. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER ST # INVOICE <br />350( ? 9, oc) 2 Li-c aca,1 4-&5hav sR# OD 2 S 2-C <br />_ _—'1/18/2000 <br />Title/Company SWF6 orhofi• 6eck-A-J1,14,p ivro,.4.411-Li :Arc I i .7—rithimuc. <br />Print Name /0/1) y <br />4 <br />/ //KAa <br />i <br />C—I—% Date ° 04°0 1 '/QigiAihiVillk I" reS r Wei- lc Flpoo " , <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 3i ,TANNA &ea <br />DEPARTMENT USE ONLY <br />2, K. , pate Issued <br />'tate ULOinal Inspection By <br />Date <br />Area <br />Date