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WELL PERMIT APPLICATION FORM UNIT IV <br /> �'� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Q� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209r 468-3449 <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/pr 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 /> Assessor's <br /> WELL Location 35275 IWQ-1 Ey R°-,d Cross StreetHwy. j�33 City Vicen,,I�5 Zip q-5385- Parcel# ass' I30'0 <br /> PROPERTY Owner �1�^ n f1�.^}L r- Address� ^� ��A✓t^ t/��J� City <e^.' Meek Zip 'lc0' Phone# <br /> C-57 Contractor Gr,­)) Dr i(tin! Address 950 /�o,,t/e. 2d. CityMu:Fi lez Zip 9Y53 Lic#165/65-Phone#_(-1c)313-S&oo <br /> Consultant/lSub Contractor GzcM 1J-riX Address 201 lv'zbSiC/ SI,tZ� City Cx�klwt�I Lic# Phone#A!4--/<3-�1/E9 <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEWELL/BORING CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) `DESTRUCTION(choose type below) <br /> SOIL BORING# GlA - GMX - 3 bx-i,r)/i Helices S fe-vl 0 OVER-BORE <br /> 0 WELL# (-IPA x I 19v yen,re Cell e c/ SL-,) )KPRESSURE GROUT <br /> -Other: 5 r- unDr ec (c <br /> COMMENTS: (�/ QwY1 f��^� ek 2 OZ <br /> TYPE OF WELL WSTALLATION E CONSTRUCTION SPECIFICATIONS V <br /> 0 MONITORING 'HOLLOW STEM (V'' DIA. OF BOREHOLE (0 to . MULTIPLE CASINGS?0 YES KNO WELL CASING DIA: AIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1VA TYPE OF CASING: 0 STEEL 0 PVC 0 bTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �7v1, h,h, iOil-TREMIE TYPE TO BE USED: AUGERS ,)- )f IOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS,30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 10' - 70' o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ^/A ( if YES,list specifications here): <br /> COMMENTS: D;,11 3 L" hICl_1Gl Stt y1 tv�c1 2 bo ,mss/) /o '10' 1bc-it4 +0 'To ' . (Alec <br /> Se l S4 r�pLt/! 4�1 �1 t 1 deafro bc•�1�c�1 C�,YIn LeMe2f �i�.•F [?luctrl fL��e��k �rtM`t Pi PF <br /> NOTE: OFFSITE BORINGS REQUIRE 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. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued,I 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 work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICAN "RS IN ADVANCE FOORR/A�LL JZEQU1�2�� SP TIOf,,-2- <br /> Signed x ✓�~' 7 ` Title-r2C�14 ' :�d+ Date l 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted By. / Date Issued <br /> Grout Inspection By Date tc �� Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> moo! 8� J ��` /oL T�2�oz �0 9 <br /> C 5?LGEISED CQNT ;CTOR 1ST � N LICENSEQR ? :' ( 11�IPE�VQ _DCLAIIQI <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />