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Dir, ' <br /> WELL PERMIT APPLICATION FORM <br /> u v NAL <br /> !,4��. CEIVE_D <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES__ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) MAR 16 2000 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 IC N�I'T �' H�A�Tr <br /> x/l.°r ! SERVICESI„�u <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> QP_Ri � s <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, EnvironmentalAssessor's Health Division. <br /> NELL Location <br /> 3� 3 f' F�Lri�tCn�� , . Cross Street �NJ City SlD�rfo�J Zip L�5 Parcel# !y3` �'1y <br /> DROPERTY Owner F 1Jj< PP;JGJI'C Address�///0'/!1 AJ • FJ.-10)� City 57ak� Zip�5"Zo 5Phone# gla5 —5105 <br /> {�irdjl:c�� J�Bdress qhs- e W1/5m V"Y . City lVfiJE, Zip 0/S_aiic# LEX27Phone# `�1n_7' 19C'LO <br /> -57 Contractors-�c'n1+fli���I:tM�;rlt��, <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> <NEW 1/VE'tL/BORING(CPT, EOPROHYDROPUNCH, HAND-AUGER,OTHER') ;DESTRUCTION(choose type below) <br /> ASO RING# S OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: IQ 1 a r <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,1 <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE, 7srJMULTIPLE CASINGS?0 YES ;14-0 WELL CASING DIA: N A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /T�YPE OF CASING: 0 STEEL O PVC 0 OTHER:__ <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -ft Stj linCe TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGEPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> APPROX. BORING DEPTH fkr IO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> SOIL BORING O HAND AUGER <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (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: "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employpersons 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, 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 x /`� r Title/Company s �fJlrt /qYn ![et4 L'kV k-,V.Jn <br /> Print Name (,',AJ I KqH Date 0- 5& <br /> S E SITE MAP IN UNIT IV WORK PLAN A ED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date ``'a5 m D <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# # <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 24012s�1 3-c Zzre <br /> 1/18/2000 <br />