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04/28/2000 06:20 2094689433 FIFTH FLOOR PAGE @- <br /> F1 <br /> 9f1PYf <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> J� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PC <br /> � <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <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 /> LL Assessors <br /> WELL Location 23(oSQ S. SGntY� � ,?or,d cross street city [ ' nn l� Tip ffG-i7 Parcel#%;1Y9-070'/0 <br /> PROPERTY OwnerOSZ Q Address Z3(oS9 j. fc n�'A t'C Ity 2ul�P-_1j Zipi .3G7 Phone#Z' 8a1-Z <br /> F r'c E �.vw me ._ 3'(4 SFev.'� O(ati Ual u <br /> _ y.5 y-"� rL525L 6(f�GS ZOy 77L-.3i 7L <br /> C-67 Contractor Addms; City.____ Zip, =Lic#- Phone# . <br /> Consultant l Sub Contractor SO(OZ Address3c0k:(,�i ll1Xte 010L Phone# <br /> GIS Coordinates:X Y ,Township 3 Range 9 YilO} Section Z 4 <br /> WORK TO BE PERFORMED <br /> JEW WELL I BORING(CPT,GIBE,HYDROPUNCH HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> W801L BORING# 0 OVER-BORE <br /> SWELL#_ 0 PRESSURE GROAT <br /> 'Other. <br /> COMMENTS; 6�apfo4,c (nortils <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING - HOLLOW STEM —� DIA,OF BOREHOLE MULTIPLE CASINGS?0 YES AO WELL CASING DIA; — <br /> p EXTRACTION 0 AIR HAMMER DRNEN CASING THICKNESS•_ TYPE OF CASING; [STEEL NC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS OSE <br /> 0 AIR SPARGE , PUSH POINT GROUT SEAL PUMPED:, Yes h No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? "6 _(if YES, list specifications here): <br /> COMMENTS: • 6P--Lf- d`Or:-iy io yS' logs (6-rrni�<c! �c-ck -to S'r4`4 <br /> NOTE: OFFSITE BORINGS REO ARE 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. Homcewner or Iloensed agent's signature certifies the following:`1 cerdfy drat in the Performance of the work <br /> for which this perrnh Is issued,I shell not employ persons subject to WORKERS'COUPENSATION Laws o(Cafifomia." Contractor's hiring or sub- <br /> contracting signature oerti0as the following:-I certify Thal In the porformanee of the work for which this permit is issued.I shall employpersons subject to <br /> WORKERS'COMPENSATION Laws of California" <br /> 6ALL,7�fEr ACTOR48fYYpk �[LHR3:IN'ADVl11UEEIORISLEXEQ;UIRED'11�SPtL�CiIOt(5; <br /> / 1#.►ffT,4 kSP_ <br /> Signed x S v Title/Company y,WO(L _4 nAcrvvtrToytA. 7J�[- PnS4k H¢921- <br /> IoNntNamr-S � Date 7-10-00 pp <br /> 77{ <br /> NI <br /> DEPARTMENT USE ONLY -7— <br /> Arerri rte , / <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destractlon Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 9 RECD BY I DATE PERNUT(SERVICE REQUEST k INVOICE <br /> .ta llJ/2�0 7-(3 Z <br /> 3501 1/18/2000 <br /> d(e_ <br /> act'., t✓ <br />