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SITE FILE ADDRESSNVORK PLAN DATE: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued 7/i'- 00 <br />Date Final Inspection By <br />Date <br />SAN JOAQUIN COUNT <br />ENVIRONMENTAI H-FAINNEn” ,5164.1 <br />Date <br />FILF COPY <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) 468-3449 <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/or install the work described. This application is made in compliance with San <br />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 />Cross Streete7Aaa:1,72) City 670c_(rroll) Parcel# Cooi:77:5 W-D/0 <br />dcW ro 1 LS 0 U.) ‘j <br />s City Zip Phone# <br />G C-57 Contractor I° Z- Z-772- I) /VI Address City Zip Lic# Phone# <br />Consultant / Sub Contractor "E9e;Ti-r,/ L L rAX:-, , Address I Z7,Z 1:14POJ 4-k City L.--,C2 D 1 <br />GIS Coordinates: X ,Y , Township Range <br />WORK TO BE PERFORMED: <br />1:1J)4•EW—WELL / BORING ( CPT, GEOPROBE, HYDROP45tH, HAND-AUGER, OTHER") <br />O.-8.01L BORING # <br />UN'Ea # Ru3 * 45 -4 <br />TYP OF WELL INSTALLATION TYPE <br />MONITORING g-FraTLOW STEM <br />0 EXTRACTION AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />[J OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 if MULTIPLE CASINGS? [J YES 11,1<r—WELL CASING DIA: I f <br />CASING THICKNESS -40 TYPE OF CASING: [J STEEL 11-KE [J OTHER: <br />DEPTH OF GROUT SEAL 5) 7 TREMIE TYPE TO BE USED: 0 AUGERS Ifil-tt:Z-E <br />GROUT SEAL PUMPED: trre-C [J No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 5-0 LI/0 11-ErirTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO (if YES, list specifications here): <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 California." <br />IV INSP TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x Title/Company F‘'(-5-174- 121-RECF\AEIEIVENE'ED <br />Print Name 84..Date <br />SEP 1 1 2000 <br />oFFIT-E <br />Lot.1 trY- <br />0-0-04\n-y RbUJ <br />WELL Location 2_ toe, <br />PROPERTY Owner <br /> <br />Zip 76-205- <br />Lic#1975-2_ Phone# (7 e:3 <br />Section <br />fl DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br />COMMENTS: <br />COMMENTS: <br />ACCOUNTING ONLY: AID# FAC# <br />iPE CODES FEE INFO <br />PERMIT! SERVICE REQUEST # INVOICE <br />AMOUNT REMITTED CHECK # <br /> REC'D BY DATE <br />1,6 <br />35ai 57 exp. WC/waiver C-57 Letter of Authorization to sign permit <br />350 / ita0 9 1401 <br />Encroachment doc(s). 5/17/00 <br />g//1/(R) sRit___72_,zA 27,