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l WELL PERMIT APPLICATION F61 UNIT 1V <br /> u x E., 1� �A��I,,JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> VIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> MAR 14 2000 (209) 468-3449 <br /> Fg'JR0l�i�l`--N A4- --iEALT�N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applrca iorJa�yin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaq��9evDme <br /> nt Title, -1115.3 9 1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> Assessor's <br /> WELL Location +��5 `ll � Cross Street ��"`�/"T�� City} 7 1 Zip�e Parcel#�j <br /> PROPERTY Owner /M,Gl Z/c 46A 4 Q Address ; g �+s fACity �aU\ 1�k_��,//Zip 9�Phonev <br /> C-57 Contractor +wgS;,741�a20 Address 2 3 r7Ety�Zip�Sp '7Lic#55� ho #��3�r��Z�p <br /> Consultant/Sub Contractor C _ __Address^7�Jr� ikhSCLlity s ic# M'7 Phone# -f" Ilk <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED �h + <br /> �EW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> -WELL# ©PRESSURE GROUT <br /> `Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l� <br /> ,U4ONiTORING fl KOLLOW STEM DIA.OF BOREHOLE /O�/eMULTIPLE CASINGS?,�ES Q NO WELL CASING DIA:{� <br /> a EXTRACTION Q AIR HAMMER/DRIVEN... CASING THICKNESS 0,GZ TYPE OF CASING:_ a STEEL _2/PVC a OTHER: <br /> 1]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL t107 SvmiTREMIE TYPE TO BE USED: AJAUGERS gHOSE <br /> B AIR SPARGE ©PUSH POINT GROUT SEAL PUMPED: ,gYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING a HAND AUGER APPROX. BORING DEPTH 0'0" RtOLTED TRAFFIC BOX or a STOVE PIPE <br /> a OTHER:_0 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: "l 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 Califomia." Contractor's hiring or sub- tt <br /> contracting signature certifies the following: '7 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to }i <br /> WORKERS'COMPENSATION Laws of California." !! <br /> CALL THE UNIT IV INSPECTOW 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> - -. _._.. .. _... . ._ .. <br /> Signed x //,�,, Title/Company <br /> rr ��f�t(i C 1� <br /> Print Name Yv� Date <br /> SEE=SITE sMAP 'LN' U.NITIVWR1'C PLAN "DATE©, .? y <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted By Date Issued 1 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date r <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 /> 1 ' f d W��� ►1 <br /> I/18/2000 <br />