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WELLSPERMIT APPLICATION FCR UNIT IV <br /> nECE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OV g <br /> ENVIRONMENTAL HEALTH DIVISION.(PHS-EHD) 2000 <br /> # 304 E. Weber, Third Floor, Stockton, CA., 952 <br /> 11209) 468-3449 �IIIVfROI�MENT HEALTH <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install thework described. This application is Evade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1'115.3 and the Standards of San Joaquin County Public Health Services,Environmental eH�lth Division. <br /> WELL Location'f n I Vrs <br /> v l �( f/ .- Cross Street RE14617 5T. Clty`ST6tx awl Zip�tS2�Z. Parcel# 1131:2-36.e- <br /> Pra1�SE t"Flr<I/i26�c7 fTEr23, ', gS11g <br /> PROPERTY Owner C J Tin! S Address 3 .MA City 570CF>eAl zip Phone# <br /> C-57 Con1ractorFAW1ei>K6S- Address YC05 )J Wu-s . A C;tySdUe6l Zi&20S List u7 Phone# 2- (6b& <br /> Consultant/Sub Contractor A cxz _ Address__S_! r 1� City . Lic# Phone# q ? - ;Qct( <br /> GIS Coordinates:X Y Township Range Section <br /> . WOR <br /> K TO BE PERFORMED <br /> 'kNEW WELL/BORING(CPT(gEOPROB YDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> SOIL BORING# 15-9 ` 10,11��3,'l!( [I OVER-BORE <br /> a ELL# 4 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE `-S" MULTIPLE CASINGS?a YES $(NO WELL CASING DIA: A <br /> o EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS 1Q TYPE OF CASING: 0 STEEL p PVC a OTHER:_�Jg <br /> o VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ZQ 3 t TREMIE TYPE TO BE USED: 4AUGERS QHOSE <br /> D <br /> AIR SPARGE PUSH POINT GROUTS EAL PUMPED:p Yes No <br /> NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> r <br /> ZO 3S BOLTED TRAFFIC BOX or STOVE PIPE <br /> SOIL BORING Q BAND AUGER APPROX.BORING DEPTH � D <br /> j]OTHER: _ p OTHER CONDUCTOR CASING PROPOSED?.N A (if YES,list specifications here}: <br /> COMMENTS: 4) SOIL t 6alA AC -T_t Zb�r 1 1) 1Tg- ba2luLr r~b 3S'` A L — <br /> Sldfl W(N iRbgaAdb il"IF147. <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. "I certify that in the performance'of the work <br /> for which this permit is issued,l shalt not employ persons subject to WORKERS' COMPENSATION Laws of Cattfomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work for whish this permit is issued,1 shall employ persons subject to <br /> WORKERS'COMPENSA TION Laws of Califomia." 1 <br /> Signed J rale STAFF � <br /> GroGIS"T -- Date t46WM8C1L 2,660-- <br /> SEE SITE MAP IN UNIT IV WORK PLAN `DATED: <br /> ,.DEPARTMENT USE ONLY <br /> Application Accepted By P.P Date Issued A0 J Area <br /> r Grout Inspection By Date inal inspection By Date ' <br /> Destruction Inspection Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArf <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# iRECP BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 0 �i G> t f �' tt . `� /tai OQ 2`f'S-IL� <br /> `st w <br /> gUNIV / 99/62kpg/MI <br /> '1 0 <br />