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FILE COPY <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) T <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 I*VI <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 /> WELL Location 11 1 o rwlroy ['L1rg n C <br /> RLV ross Street t oN 1iN AVFCit �yp� Assessor's <br /> E y Tc Zip 21S2or-1 Parcel# /7-309030 <br /> PROPERTY OwnerAddress <br /> 7151 CCx.NtoV rr. g city_StpCL-ir-N ZiP`I 204 Phone#ezn•r�271$ <br /> C-57 Contractor C65CADF r)RII LLMC Address3b32 cmrt, CTRc LF Cit RonrvcHooa <br /> ADVANCEb C-EC� Y r c+tA Zip gS`42 Lic#7175i0 Phone#!q 61f <br /> Consultant/,Sub Contractor ENVZ0.IXVMFNTAt_ T AddressSNAW pD4 CitySTucKrc;NLic# Phone# (zc.9)vf-'1-ror-c_ <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> .1 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) D DESTRUCTION(choose type below) <br /> D SOIL BORING# 0 OVER-BORE <br /> SWELL <br /> 'Other: MW�13.MW-1�{.MW� IS,114%1-.I f. OPRESSURE GROUT <br /> COMMENTS: REFERENCE. ATTACI-1P D WORK PLAN DA-rG:D 15 TANVAR'f 2C-0-7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> S MONITORING ,HOLLOW STEM DIA. OF BOREHOLE_MULTIPLE CASINGS7AYES 0 NO WELL CASING DIA: 2-- <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS akvtsoy t Ao TYPE OF CASING: D STEEL - PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IC 6 S rase TREMIE TYPE TO BE USED: TIAUGERS DHOSE <br /> 0 AIR SPARGE E PUSH POINT GROUT SEAL PUMPED: :KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER APPROX. BORING DEPTH SO ANO SO J WOLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER-_a OTHER CONDUCTOR CASING PROPOSED? t.4 A (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." Contractors 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 THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed xc <br /> f7A—e_ Title/Company STAFF mFNYr TJAoVANCFO t EC•FNl�s eoclhENTq� <br /> Print Name PiECKY LEE _ Date 212310-1 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY 2 / c-�/ <br /> Application Accepted By�Date Issued...:..: L'1 �� I Area OBJ�/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 257-}2ONJAz-23050(o5F <br /> 1/18/2000 <br />