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May 02 00 08: 50a HN'T1RO-GEO CONSULTRNTS, INC G50-428-0589 p. l <br /> WELL PERMIT APPLICATION FORM 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 PERhllT 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 is madin compliance with <br /> e <br /> San Joaquin County Development Title,Chapter 9-1 1 15.3 and the Standards of San Joaquin County Public Health Services, r-na ental Health Division <br /> WELLLocation 2-.12- N- Suf>tCr� <br /> , _ rrzip? <br /> 7,72 <br /> o L._Assessor3 <br /> 's <br /> A�Cross Street E. 1"7,'17e 0-- City S Parcel"/PROPERTY <br /> oss <br /> '/ Phor,eT � e7. <br /> C-57 Contractor Y/IVO//C X Address 23762 Fo( S f # <br /> !� �_City IPn.en� zip9ysyrlc» DSg2�Phcne' E/o266-p <br /> Consultant/Sub Contractor./yy�Y0-�,cPa CO 210 Address/0 66 <br /> City/It.!/J�4, Lic:NCS7s phcr,e 6So Z$bStc <br /> GIS Coordinates:X Y ,Township <br /> Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/GORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: P//t Ce T--P S y ,o2g/3t'S C e/c(=/oL L D rvl r� �CQ 0 PRESSURE GROUT <br /> COMMENTS: T- C Ep,E.v T-- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES <br /> 0 EXTRACTION 0 AtR HAM v1ER/DRIVEN CASING THICKNESS 0 0 NO WELL CASING DIA: <br /> TYPE OF CASING: 0 STEEL 0 FVC0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL___^TREMIE TYPE TO BE USED: 0 AUGERS <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes OHDSE <br /> Q SOIL BORING D No {NOTE: MAXIMUM FRE,=-FALL DEPTH IS 30') <br /> 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or <br /> 0 OTHER: _0 OTHER CONDUCTOR CASING PROPOSED? D STOVE PIPE <br /> (if YES,list specifications here): <br /> COMMENTS: %D /3r 54--`.444rD /YN.+� cp(,ciTc`LY /EFTcj2 S .q.r� PLi�/G_ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the war k wilt be done in accordance with Sar.Joaquin County Ordinances, State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the work <br /> for which this permit is issued, 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the ovork for which this permit is issued, !shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California," <br /> TH APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECT!ONS <br /> Signed x <br /> Title(1 tYYr ��t.Y <br /> SEE IT <br /> MDale., <br /> IN UNIT IV WORK PLAN DATED' Z! <br /> DEPARTMENT USE ONLY <br /> Application Accepted By C,% Date Issued � Z OU <br /> Area <br /> Grout Inspection By 1c,,.1 vF a Date 22 Final Inspection ByDa, <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> FACCOUNTING ONLY: AID.ES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPERh11T I SERVICE REQUEST# 1NV010E <br /> lnfc S�z oo ZZ� z.( <br /> C-57.LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />