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Application is hereby made to <br />Joaquin County Development <br />WELL Location 2. <br />PROPERTY Owner C ' • <br />2- I , <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />lat.-SOF() 1/Cross StreetnnialLZWZ City --FC7C-k--T0 d Zip %--205— Parcel# C00#;.)-735: <br />) <br />,67-11 dcrs FO le— IVL ..)4j City Zip Phone# <br />()(TE 41012 <br />\ UiLLi try' <br />RbtkJ <br />WELL PERMIT APPLICATION FORM <br />C-57 Contractor Address <br />Consultant / Sub Contractor T3 LL /-"Vot Address I Z7n fi•;;I:Vj 4-k City i Lic# /975-2_, Phone# c-)2 F3 ( <br />City Zip Lic# Phone# <br />, Y , Township Range Section GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />40:4-Elg-WELL / BORING ( CPT, GEOPROBE, HYDROP421-1, HAND-AUGER, OTHER*) <br />(p8OIL BORING # <br />WEEL# NAdo r 41) <br />COMMENTS: <br />*Other: <br />O DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />Title/Company <br />124/ A <br /> <br />rir -F_A)7c,42.c, 84:Date <br /> <br />RECEIVED <br />TYP OF WELL INSTALLATION TYPE <br />MONITORING WI-6110W STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />Ei AIR SPARGE fl PUSH POINT <br />O SOIL BORING fl HAND AUGER <br />0 OTHER: UOTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 if MULTIPLE CASINGS? 0 YES 11,1‘--WELL CASING DIA: E <br />CASING THICKNESS d 40 TYPE OF CASING: USTEEL tg--KE OTHER: <br />DEPTH OF GROUT SEAL,Di- 75 TREMIE TYPE TO BE USED: U AUGERS Xl-Hin-E <br />GROUT SEAL PUMPED: frre-c No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH _57.2 L /i0 I a-K5-11TED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Irl.) ( 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 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: "/ 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: "/ 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 California.- <br />E U IV INSP TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x <br />Print Name <br />SEP 1 1 2000 <br />SITE FILE ADDRESS/WORK PLAN DATE: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued____________ <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: (1)12e,e4 -Z7‘0-3161-. <br />Final Inspection By <br />SAN JOAQUIN COUNT <br />ACCOUNTING ONLY: AID# FAC,# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />55°1 /VW '5 7 1/to--7 t6 c141/ov -SR# 0 .• g." _ <br />_35D) 57 exp. WC/waiver C-57 Letter of Authorization to sign permit <br /> <br />Encroachment oc s <br />