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10-18-1999 2:02PM FROM P- 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> CQ::C:i <br /> Y PUBLIC HEALTH SERVICES <br /> u SEP 1 $ 2000 EALTH DIVISION (PHS-EHD) <br /> Floor, Stockton, CA., 95202 <br /> 9) 468-3449 <br /> � RVICES <br /> pp��R[ M TSE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppligiA 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 Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health$ervIcces,Environmental Health Division. <br /> WELL Location ��0� 2 si�O� C�Cr�oss S reel ll l,S�QA/ City /14G Zip `. �b PAssesMsor's <br /> �11,, I 71IISe <br /> PROPERTY Owner Lp�TG Lo l o'ey lA Addresses YSlm �zCity �y,/r/�/ zin1"2/4hone#�f- �404( " <br /> C57 Contractor f- vii llCp,,,,,Address Cay �,/26/��fp yr Lic# Phone# <br /> u "C7!/Ifi'ry Address IM110� /9-Yfi4!/�C C t — !' ic4 Phone# s '313 5�+ <br /> Consultant t Sub Coni�aCtor__ <br /> !!�� / // ^ � <br /> GIS Coordinates:X See bell Se�lu/sLJ .Township - d 5 Range Section_ <br /> \YXRK TO BE PERFORMED <br /> 6MEw WELL/BORING(OPT. GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 777\\\ 13 SOIL BORING# U OVER-BORE <br /> 'Other. -� # O� aPRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL �IINNSTALLATION TYPE CONSTRUCTION SPECIFICATION$ <br /> U MONITORING yHOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?D YES NO WELL CASING OIA:_ <br /> U EXTRACTION U`AIR HAMMERIDRIVEN CASING THICKNESS�'4A q0 TYPE OF CASING: []STEEL -PVC U OTHER: <br /> `VAPOR U MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: U AUGERS UHOSE <br /> 0 AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> U SOIL BORING U HANG AUGER APPROX.BORING DEPTH r,S/ *OLTED TRAFFIC BOX or U STOVE PIPE <br /> n OTHER:—n OTHER CONDUCTOR CASING PROPOSED?_L0 (if YES,list specifications here): <br /> COMMENTS: 4/4 yt' A All l(,Jei /�kS! /JI/t� �Q-f QSP/P 5 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this appli0atbn and that the w"will be done in accordance with San Joaquin County Ordinances,State Laws, R <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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of Califomia." Contractor's hiring or sub. <br /> oontrading signature certifies the following 1 certify that in the performance of the work for whioh this pemrit is issued. I shall employ persons subject to <br /> WORKERS'COMP NSATION Laws Of fvrnia." <br /> E PpLIC TGA WORKING'HRS IN`ADVANC�FO 'ALL RECHAREp INSR CT NS. <br /> Signed x � �.. �... Title -Dale <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> ApplicationAcoeptedBy_ Datelssuea 9/ -Late ° Area eUr2cJ C-q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date - <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> AN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST k INVOICE <br /> �-qoi n 8r -T 7,T - / 111 -Tzb oo Sg# <br /> C-57110ENSED CONTRACTOR NU PST SIGNI_ICENSE&WORKERS. COMPENSATION DECLARATION <br /> UNrT IV'6/23/99/sign bkpg/MI <br />