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WELL PERMIT APkICATION F M UNIT IV <br /> RE.CE1VF+1ioAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> VI NM TAL HEALTH 1 <br /> RO EN HDIVI SON ("PHS-EHD") FU <br /> DEC 2 8 1999 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENTAL HEALTH <br /> (209) 468-3450 <br /> PERMIT/ SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> P.pplication 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 /> CO3n+1,y CIv6 6lub• Asiessors <br /> WELL Location IsS�O co��n� I �)v0 ross Street Mi55c n R.Ae City `J?ecK ren Tap S O Parcel# <br /> PROPERTY Owner 420 W• yoS 'bP # 9'6-Eq £ eryAt3o L3-7 3 <br /> C-57 Contractor Acl.rar x eO Fn�;rnn��Add�ss y Q aS M, Iry�)snr�a Vfi�ity S Toc.K 7)r1Zip 95z Uc# b94D"7Phorve# Z ocr 4-71 oe�n <br /> -gpeawksm-'bub Contractor M i�c�n I1 Ar 1 lino �hyAddress 5'S{na S �"R�Rn..r CityL &&91 Uc#�� Z�i 7 Phone#Q I -3S IP 4 k b 3 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> IEW WELL/BORING(CPT.GEOPROBE;HYDROPUNCH,HAND-AUGER.OTHER-) 0 DESTRUCTION(choose type below) <br /> \ 0 SOIL BORING# ` a OVER-BORE <br /> 0 WELL# MMJ"1 . M�' 0 PRESSUV GROUT <br /> -Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> �ONITORING NIR <br /> OLLOW STEM DIA.OF BOREHOLE $-in l <br /> MULTIPLE CASINGS?Q YES� WELL CASING DIA:Z-rK� <br /> p°XTRACTION HAMMER/DRIVEN CASOG THICKNESS4)4%, 4o TYPE OF CASING: Q STEEL PVC 0 OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL1=oa l TREMIE TYPE TO BE USED AUGERS GHCSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH A2ao o LTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER CONDUCTOR CASING PROPOSED? (it Es,list specifications here): <br /> COMMENTS: -- <br /> t NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> hereby Certify that I have prepared this application and that the wont 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 /> .'or 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 following:'I certify that in the performance of the work for M7=this permit is issued. I snail employ persons subject to <br /> WORKMAArS COMPENSATION Laws of C&Womia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVAN OR ALL REQUIRED INSPECTIONS. <br /> Signed x Tit T C4051)�Date �� r <br /> SEE SITE MA INI UNIT IV WORK PLAN. DATED <br /> „(DEPARTMENT USE ONLY Viv- /i .V IJ Area <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: D <br /> FAC# l <br /> ACCOUNTING ONLY: fAI;7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED BY , DATE' µPERMIT/SERVICE REQUEST NUMBER ` INVOICE <br /> yD !oAL 2 ZS 00 5 <br /> UNIT IV-5/99/MI <br />