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FROM WILLIAM DUBOVS.1�-ENVIRONMENTAL PHONE NO. : 448 25...,d2G Pg <br /> WELL PERMIT APPLICATION FORM,, UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL-CH DIVI:SION`,(RIi5�06) ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209x488-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfgr install the work described. This apWlcallon Is made in compliance with <br /> San Joaquin County Development Title.Chapter 9.1115.3 and the Standards of Sen Joaquin County Public Health Services,Environmental Health Division. <br /> Asseasoi s <br /> WELL Location 2373 Mariposa $pad Cross Street Furwin8tc, ity Stockton 21095' PorcalvUL 300/09 <br /> PROPERTY OvtnerHusky Crane � Address Mariposa Rdt ty SCoc kton�Ip95201phonooS800)(292_37 <br /> C-3TContractor HEW Dr111 ins Addreaa 1045 Wenlr qr Cay�e,.sL-YIR.A �iB# 6049$�pr,N,,(65())322-285 <br /> Consultant/Sub Contractor WI1F AdpressP- 0. hnz 99 Gey F,l Doradba 66 U0 -43 <br /> GIS Coordinates:X_,_, .Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> X a NEW WELL I BORING(CFI,GEOPROBE,HYDROPUNCH.HANG-AUGER.OTHER-) Q DESTRUCTION(Choose type below) <br /> AMII.BORINGA NO. 10 OVER-SORE <br /> 0 WELL* Il PRESSURE GROUT <br /> 'Other: - - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE C N TRUCTION SPECIFICATIONS <br /> Q MONITORING 19*MUMW9STEM DIA.OF BOREHOLE MUL'I IPLE CASINGS?0 YES ONO WELL CASING DIA:— <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE Or CASING. 0 STEEL D PVC 0 OTHER' <br /> O VAPOR 0 MUD ROTARY DEPTH OF UROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yea Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> li,99do WORNG D HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER:_ Q OTHEhL CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 1 <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS C <br /> V <br /> I hereby certify that I have prepared this application and that the work will be done In accord-ante with Sen 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 corff/y,that In the performance of the work <br /> for which this perm/f is issuso,I shah not employ persona subject to WORKERS'COMPENSATION Laws of Callfomia." Contraclor'a hiring or sub- <br /> conlrectkp signature certifies the following: 'I oarfify that in file performance of the work for which this permit is Issued.I shall employ persons subgeot to <br /> Wt7RKERS'COMPENSPT'ON lewd OI CeMomk+," <br /> T E APPLICANT UST GALL HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Sig Date /21/9 9 <br /> SEE SITE'44 IN UNIT IV WORK PLAN DATED 7/30/99 <br /> DEPARTMENT USE ONLY -7 ap <br /> Appikatbn ArrApfed By - Date Issued Z��-/-/ Area Q� <br /> Grout Inspection By Data— Flnol Inspection By to <br /> Destruction Inspection By Date 901 <br /> COMMENTS I CONDITIONS: SV46f <br /> /lam T522 <br /> ACCOUNTING ONLY: AIDit FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED DY DATE PERMITISERVICE REQUEST NUMBER INVOIC <br /> # <br /> C,57.,.'�5�1?:��1d�'�;A <br /> UNIT IV.6/23/99/sign bkpg/MI <br />