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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 FILE COPY <br /> (209p 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/Qr 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 /> �+1eSk a t: Assessor's <br /> WELL Location Zto 501 $o✓-FL. Barrh'. (loaaf Cross Street 4Jlb S4-. Cityroc Zip 5^37(o Parcew 'l52'07-at[ <br /> SIL.yo <br /> N <br /> PROPERTY Owner CA.l��ornia NeMtiot Ro a&U Adpdress Zr12I C�Aet�o.y F41 City,* G— Zip S"S8 Phone#�jb7)1sy-IYjy <br /> C-57 Contractor Gleca &;I/;," Address /50 nota[ Qooe( CityljkdL inez Zipi Lic#"SMISPhone#(925�313'S800 <br /> Consultant ub Contractor GeorMm-Frri Address 2l01SI-City�Q. J Uc# Phone SIOi(o63-11/69 <br /> GIS Coordinates:X Y Township Z -Is rr . Range S E46 f Section S.r <br /> WORK TO BE PERFORMED <br /> We\L MLJ-S <br /> Q NEW WELL/BORING(CPT, GEOPROBE.HYDROPUNCH, HAND-AUGER,OTHER-) YDESTRUCTION(choose type below) <br /> Q SOIL BORING# OVER-BORE <br /> 'Other: Q WELL# [ PRESSURE GROUT <br /> COMMENTS: Ar-st-e*yn Mct'kod <br /> TYPE OF WELL -lNfiT*k*AT"TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA. OF BOREHOLE__MULTIPLE CASINGS?Q YES XNO WELL CASING DIA: A111 <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS A/A TYPE OF CASING: Q STEEL )(PVC Q OTHER- <br /> — <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL Al A' TREMIE TYPE TO BE USED: Q AUGERS *OSE <br /> Q AIR SPARGE Q PUSH.POINT GROUT SEAL PUMPED: Q Yes A No,(NOTE;MAXIMUM FREE-FALL DEPTH IS,30') <br /> Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 2S Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER:_0 OTHER CONDUCTOR CASING <br /> �PROPOSED?�(if YES,list specifications here): <br /> COMMENTS:-Des 3-/oc /vLoni Fwi AJ /-I w-S s,{- f�{ TcyN6H (yo Locd.ns ,S{d•fs�A/t b� O'✓tti-cI/il/rtar <br /> 2° Ole. PUG t.wl >'y (m{r.4 dalplil - Boiinc fv be Fio {iona betAavt 4o o uiiL Tituit <br /> NOTE: OFFSITE BORINGS REQUIRE AC ESS OR ENCROACHMENT PERMITS Pipe. <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: 'Y 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 /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE/FOR ALL REQUIRED INSPECTIONS. <br /> Signed x J,,��,/ A) D ez Title LO eo I u(S>L Date 7IS1 D 1 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 05- T <br /> Application Accepted BywlD�\ Date Issued Area(li✓1 t✓LC.) <br /> Grout Inspection By Date Final Inspectio By <br /> Destruction Inspection By Date p <br /> COMMENTS I CONDITIONS: t) n L✓62C ,, AA P <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECOCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ,151 66— <br /> G,57CQI3S� X1I LTCEL�f -*M"K .'.CGCyl�tl? IA { �1F)ECI tS.)2t1IQ1 <br /> UNIT IV-6/23/99/sign bkpg/MI <br />