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WELAI ERMIT APPLICATION *M 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 mace to San Joaquin County for a permit to construct andtor 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 942 South Stockton Ave-Cross street Cary Ripon Zip 95366 Parcel#Assessor 2`59-340-01 <br /> PROPERTY Owner Fox River Paper Co. Address 942 S. Stockton Avt�in, Ripon Zip 95366 Phone# (209).599-0248 <br /> C-57 Contractor Spectrum Explor.A91ka, Inc 2365 Wigwam DE$, Stockto5 952UC*512268pnone# (209)465-87I2 <br /> Consultant/Sub Contractor ERM West Address 1809 N. Helm Ave City Fresno Lic# Phone# (559)452-8010 <br /> GIS Coordinates:X_, YTownship T.2S. Range R•8E• Section 29 <br /> WORK TO BE PERFORMED - <br /> T,NEW WELL/BORING(CPT,GEOPROBE. HYDROPUNCH,HANO-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> 'Other: WELL# M-26C2 a PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MCNITORING a HOLLOW STEM OIA.OF BOREHOLE "+MULTIPLE CASINGS?a YES )&NO WELL CASING DIA: 211 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ached. 80TYPE CF CASING: a STEEL PVC a OTHER: <br /> ]VAPOR )g MUD ROTARY DEPTH OF GROUT SEAL 188'bgs ;REMIE TYPE TO BE USED: 0 AUGERS aHOSE <br /> VCpiF <br /> ]AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALLDEPTHIS 301) <br /> ]SOIL BORING a HAND AUGER APPROX. BORING DEPTH 200' a BOLTED TRAFFIC BOX or ti STOVE PIPE <br /> ]OTHER: a OTHER CONDUCTOR CASING PROPOSEED? ( If YES, list specifications here): <br /> 30MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> herecy 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 Ire" <br /> Ind 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 WORKERS'COMPENSAT70N Laws of California." Contractors hiring or sup- �.�r..�. <br /> tracz nature certifies the following: Y certify rhat in the performance of the work for wnich this permit is issued, I shall employ persons subject to <br /> ■ <br /> ZS'CC PENSAT/ON Laws of California.' <br /> THE APP ICANT ST ALL 48 HRS IN ADVANC OR ALL REQUIRED INSPECTIONS. rVI <br /> p� <br /> Signecill <br /> d x Title �tX O�. Date O c/ti <br /> SEE SI E MAP I UNIT IV WORK PLAN DATED b—ftoo <br /> ll , 1 DEPARTMENT USE ONLY �(� 1 <br /> 1PPlication Accepted By \ ti\ W Date Issued o o <br /> 3rout Inspection By �'��y.Ipti,,ria` _Date_IA IOIOO Final Inspection By `, R pate It 0 C, <br /> )es[mC10n Inspection By Date <br /> .OMMENTS/CONDITIONS: C.yN c <br /> ACCOUNTING ONLY: AID# i rAC# ENV)PpNN <br /> PE CODES F-cE INFO AMOUNT REMITTE CHECK#I ASH I RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLAR-ATION <br /> 1NI7:V-6/23/99/sign bkpg/MI <br />