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NAM.,/ <br /> WELL PERMIT APPLICATION FOKM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 /> sTO�LK'ron C- WEST: Ltgti . Assessor's <br /> WELL Location 323 p noo <br /> IV, 1�1FS T LAn)�y Cross Street = AhOME AVE. i <br /> VE.City 5 x—KToreip 95Z.0 5 Parcel# <br /> PROPERTY Owner NW IJP loI EA'f Address f.0. SoA 1/rJ-T City 5Tcct0on Zip°I52ol Phone#219.4 toy 3Ytl <br /> C c <br /> C-57 Contractor M;-kht II nDA t I1 Gll0_Address 536 0 --bv TH Wo}}AUf City-�u�,c�(t��'rnPp ip 951i`2U Lic# 726 Phone#9I b- S5 6 V b b t <br /> Consultant/Sub Contractor A�G. �. Address Yo 0 .9 N. W11150 G1ty S la�K?onl/Lic# 80 7 Phone# ZQA- Yb7-loo <br /> GIS Coordinates:X Y ,Township IJ Range to F Section 3 O <br /> WORK TO BE PERFORMED <br /> S3JI i!_�5/11W <br /> 3,J 3,V J_NTANCNI.AN3 <br /> &NEW WELL/BORING(CPT,GEOPROBE, HYDRQPUNCH, HAND-AUGER,ot4ttO DESTRUCTION(choose type below) <br /> ,SOIL BORING# F-7 c� d� a OVER-BORE <br /> SWELL# MWJ-1 7-} a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: 1s .. 2 1 i <br /> ]L-- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE $v " MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: Z <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS�A Ovit `0 TYPE OF CASING: 0 STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Yo V$-0- )5%- TREMIE TYPE TO BE USED: )&AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,IK-'es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 65 EE E-1- BS(P;KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? u a (if YES,list specifications here): <br /> J45F- <br /> COMMENTS: 5 F_ Ap_pr&vFD WGrK 3Q Ari DgTED of ll:168vAAy 2000 <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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 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 <br /> �INSPECTIONS. <br /> Signed x Title/Company Q d o f-I,/DV NC4p G;E-01�0JV,ioAMV11 <br /> Print NameDate <br /> SEE SITE' MAP. IN UNIT IV WORK 5U4N DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued S��6l Area O 7 <br /> -G r <br /> Grout Inspection By �`�c ��, /I16�j Date . -r_-dam__ Final Inspection By Date <br /> Destruction Inspection By Ij Date -f ce� ir, <br /> v <br /> COMMENTS I CONDITIONS: 2 r+Gl! �n LJs oc�r ac+�- �� ✓ ' <br /> ACCOUNTING ONLY: AID# FArjt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 30021" <br /> 1/18/2000 <br />