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• t � <br /> WELL PERMIT APPLICATION FORM F " <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 5� ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) <br /> Qt 304 E. Weber, Third Floor, Stockton, CA., 95202 « ��_ <br /> (209) 468-3449 f <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication is made In compliance with San <br /> Application Is hereby made to San Joaquin County for a penult to construct and/or install the work described. This a <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental HHeall SDivision. <br /> WELL Location�S �� �Q' I/ <br /> o� Cross Street irClty Tl�LP �Parcel# ZYIo—!30 6g <br /> a1aO�� City � 6 <br /> PROPERTY Owne -oCA� an1rAdress _22! 9 <br /> �� rQa( City/�lQ Heir Zip4/ LIdF$�S/6SPhone#�S-- -S 4 <br /> C-57 Contractor4Jr i din- Address`TS-b/Td �Y9 fie�o C <br /> /94�og/.Y/ e%�✓ Address�ea6erf.T/n�.(�u+r City_r�N�s Llc# Phone#9l6 '47 <br /> .41j <br /> Consultant I Sub Contractor <br /> ,. YL/5'75X YYS,Township dZ.S Range 4L5 Section '3 <br /> GIS Coordinates:YG1T 9'/elf�`/S.Y� <br /> WORK TO BE PERFORMED: <br /> DESTRUCTION(choose type below) <br /> D NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D OVER-BORE <br /> D SOIL BORING# I'PRESSURE GROUT <br /> DWELL# <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALS TYPE CONSTRUCTION SPECIFICATIONS ULTIPLE CASINGS?DYES ONO WELL CASING DIA:__ <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE <br /> AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D EXTRACTION D DEPTH OF GROUT SEAL TREMIE TYPE TO 8E USED: D AUGERS DHOSE <br /> D VAPOR D MUD ROTARY <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Dyes D No (NOTE: o (DTRAFFREE-FALL DEOVPIPE <br /> 30 <br /> D SOIL BORING a HAND AUGER APPROX.BORING DEPTH D <br /> D OTHER: n OTHER CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this appgcatlon and that the work will be done in accordance with San Joaquin Counthat ty Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner rsons subject to censed nWORKERsignature COMPENSATION Laws o Ca-eril�ldmlel•"tCon6a tor'srson hiring ct sub- <br /> and <br /> work <br /> forwhlch this permit is Issued,I shall not employ pe I <br /> contracting signature certifies the following:I certify that In the performance of the work for which this permit Is Issued,!shall empbypersons subject o <br /> WORKERS'COMPENSATION Laws of Cal#omla.' <br /> LL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> isLelpr6 <br /> for � l <br /> x <br /> Signed "" u� TNIelCampany / 0 <br /> y�Gs Date �//9lyZ w: V!►K �IC <br /> Print Name 'on/7i-S <br /> SEE S MAP IN UNIT IV WORK PLAN DATED: 3 2} b2 <br /> DEP TMENT USE ONI Y <br /> 3 O Z— Area <br /> Date Issued 2 <br /> Application Accepted BY Final Inspection B Data <br /> Date <br /> Grout Inspection Dy Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# E REQUEST t INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK ti RECD BY DATE P b� 6g <br /> ga 2 W (00 555 5- <br /> 5/15/2000 <br /> E0 3Jt7d <br /> 600-U H1AId EEVE09460L 61:91 000L/91/90 <br />