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t <br /> D � jIWELL ERMIT APPLICATION FC9 M UNIT IV <br /> 42000 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILE COPY <br /> MAY ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVPERMI E;SER HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 0417 <br /> PERMIT/SERVICES (209) 468-3449 7ti <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (i 17�— <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 <br /> San Joaquin County Development Title, Chi er 9-1115.3 and the Standards of San Joaquin Count Public Health Services, Environmental Health Division. <br /> Db�f Wit C-c �,y� — y P Assessor's ,r <br /> WELL Location 2 7� 11W��i �7-' �1Gross Street� // QC Cit C Zi �������p Parcel# jfiJtfr�"r <br /> PROPERTY Owner� ( 1 _ _Address _6 " f`�'7 City J� Zip rJ�`.�'4--Phbne#1 <br /> C-57 Contractor �' {Jf` ' I Address I�U /�"",'rr City r ,g`''`' +Pgic#��9✓,1P�, Phone# <br /> Consultant/Sub Contractorilf) f ddress�6 NIZ1 Yv lityc#�!/Oa�c7 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> KNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> Q SOIL BORING# 0 OVER-BORE <br /> 0 WELL# U� �� 0 PRESSURE GROUT <br /> 'Other: V <br /> CCMiMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI ATIONS !) <br /> MONITORING a-HOLLOW STEM DIA. OF BOREHOLE *2,4d" MULTIPLE CASINGS?0 YES .,8'160 WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ff-15-VC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5WAfWte– TREMIE TYPE TO BE USED: XAUGERS OSE <br /> 0 AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,eSOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 109 ieV-f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> A <br /> COMMENTS: <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'COMPENSAT ION 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'COf✓PENSAT/ON Laws of California." <br /> CALLTHE <br /> ,UNIT�PECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed xyZu�Vw _ Title/Company Li LC, <br /> Print Name � � rte.! S ZZ� , <br /> 3�vov o� <br /> ��// Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY (X� <br /> Application Accepted By Date Issued IZ /_3 — o O Area <br /> Grout Inspection By Date i in By to <br /> Destruction Inspection By Date <br /> i <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACIt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z90I E • l42 yj 2 E/P <br /> ti1\o� 1/18/2000 <br />