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10/11/2092 16 21 2094683433 FIFTH FLOOR PAGE 02 <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) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 10plication is hereby made to San Joaquin County for a permit to construct andlor 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 /> 1001 F.`faSI;MITE AVF-, Assessors <br /> IVELLLocation toss AYE City NIIlNt£Cp 2lp9ar336 Parcells x23"140'43 <br /> PROPERTYOwner VikAAhAJK. INC. Address 141'43 KNOLtVIEW DR. CityDANVILtE, Zip9_4S115 Phone# (925)945-IIS$ <br /> 57Contractor 1117CIIE.LL DRILLINCrAddress 10616 MII,A110 WAY CityRAMCHO Zip956-fOLic#6}761}Phonett 9l6 631.35B3 <br /> GOR DOVA 1111.roo <br /> Consultant I Sub Contractor R A M A ref P-N V, _ Address F 0, d px f 6 9 City RAHfHG Lict1 5 3 G Phone# 0916 3SI-3750 <br /> ----- 11ptlF ETR <br /> it15 Coordinates X Y� Township Range Section <br /> m1VORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT GEOPROBE HYDROPUNCH BAND AUGER,OTHER') (J DESTRUCTION(choose type below) <br /> 0 SOIL BORING 0 0 OVERBORE <br /> J WELL X MW-S 0 PRESSURE GROUT <br /> ,Other <br /> OMMENTS <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING III HOLLOW STEM DIA OF BOREHOLE B`IN MULTIPLE CASINGS?0 YES I NO WELL CASING DIA x'IN <br /> EXTRACTION D AIR HAMME"RIVEN CASING THICKNESS N14 40 TYPE OF CASING d STEEL 0 PVC 0 OTHER <br /> OR 0 MUD ROTARY DEPTH OF GROUT SEAL 13-f f- TREMIE TYPE TO BE USED 13 AUGERS OHOSE <br /> SPARGE Q PUSH POINT GROUT SEAL PUMPED 0 Yes III No (NOTE MAXIMUM FREE-FALL DEPTH IS 301 <br /> 0 SOIL BORING p HAND AUGER APPROX BORING DEPTH 30-FT, 1 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> IOTHER CONDUCTOR CASING PROPOSED? NO (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 apphption and that the work will be done in ateomance with San Joaquin County Ordinances State taws,and Rules <br /> 10ritracting <br /> d Regulations of the San Joaquin County Homeowner orhoense¢agents signature certifies the following "I eertrly that to theperformance of the work <br /> rwhich this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California" contractor s hiring or sub signature certifies the following 7 Cattily that in the perform8nce of the work for which fhrS permit is issued I shall employ persons subject to <br /> MRKMAN S COMPENSA TION Laws of Calrfomia " <br /> THE PP ICAN TC 48 HRS IN ADVANCE FOR AL REQUIRED INSPECTIONS <br /> tgned x <br /> Title eroo! Oate,T— `-" ~O Z <br /> EE SITE MAP IN NIT IV WORK PLAN DATED s zC of <br /> rEiPJ)TLNMEN7 USE ONLY <br /> e Issued "Dat --Area <br /> — <br /> Application Accepted By Date_,,, <br /> rout Inspection By Date Finer Inspection By <br /> estrvcGon Inspection By Dale <br /> COMMENTS 1 CONDITIONS <br /> FACP <br /> OUNTING ONLY AID# <br /> COt]ES FEE INFO AMOUNT REMiTTEU CHECKNICASH RECEI D BY DATE pERMtTlSERVICE�EQUE5T NUMBER INVOICE <br /> 3 <br /> r O <br /> ,UNIT TV 6/1/49/srgn b1kP9/MI <br />