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�\ <br /> WELL PERMIT APPLICATION FORM UNIT Iv <br /> Q `25 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Oil ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> e.\V. 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 0� (209)468-3449 it <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 San <br /> Joaquin�po�ntyyDevelopment Tide,Chapter 9-1115.3 and the Standards of <br /> San Joaquin County Public Health Servlces�Enzvirroo�nme tel Health <br /> sDivision. <br /> rV 1_6Q_-6/4ClfJ/K 4t Cross Street.✓t�Cn _City%r�"«i Lp�-Parcel# <br /> WELL Lova an - f, —T_ T t/ <br /> PROPERTY Owner(�k� flare Zrr[4 ie It Addressi97_TrO� .�vd City-%r�v�i—Zlp���Phane#zog 8.3J RSCS' <br /> CSf Conlado '-" :g; Address lS7S <br /> a�city/��' 7C�-ZiPry. `fLlciF`18fLSPhane#9LS-3/� •S�O� <br /> �Sr9/SES zoa �L <br /> Consultant 1 Sub Contracto� Gfdn/ll/ aK�/r�Address� 'J Cityd <br /> G )L!CK•39• /a8�5'S.Y G^e u• yTownship d <br /> ZS Range 6 S-� Section -Z <br /> IS Coordinates: <br /> WORK TO BE PERFORMED: \ ' <br /> �'bESTRUCTIOf!V(choose ER-type below) <br /> ,IEW WELL I BORING(CPT,GEOPROBE.HYDROPUNCH,HANG-AUGER,OTHER-) `C/f OVER-BORE <br /> Q BOIL BORING# � !/ o PRESSURE GROUT <br /> p W ELL# <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES Q NO WELL CASING DIA:_ <br /> a EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASTING: USTEEL EMIE TO BE USED V PC 0 0 OTHEGERS • OHOSE <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER APPROX,BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER: f1 OTHER CONDUCTOR CASING PROPOSED4 (If YES,list specifications here): <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> State I hereby end Raga tions of I have he San Joaq�CountyU Is ^Homeowne011 hor ws,and Rules <br /> a.U enso d 91e et'e signatture fiess the follllowing•7 certify thatt Inl the performance Of the work <br /> contracilng or sub- <br /> h this atureHcIs lasued,I shelf eNfies the following:'I certify thaemploy t in the performancee ons Subject to of the work forwhich this perATIONmit is issued,!of f shell employersons subject to <br /> WO S,DO SA TION Laws of California.' <br /> " CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> TltlelComp2nq �v'r 6i o Erf�ieo� ,era <br /> Signedx <br /> PrMtName ✓���/'f Datep <br /> SEE SITE MAP IN UNIT Iv WORK PLAN DATED: '3! 0Z�^ W-[l�-�r`� <br /> DEPARTMENTUSEONL <br /> Date Issued -02- Area <br /> Application Accepted BY Final Inspection BY Date <br /> Grout Inspection By Date <br /> Destruction InapeOdon By Date Q <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS <br /> RECD BY DATE P E REQUERT t INVOICE <br /> b y — ss�f 'G* i s- ► DOz 68 <br /> 5/15/2000 <br /> E0 39tld <br /> 800-U H1dId CEP66906OZ 61:51 000Z/91/90 <br />