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WEAERMIT APPLICATION AM 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 I 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 <br /> San Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> ��1.r / ( .L f1 (' ���rrr--- """```'''��' <br /> Assessor's <br /> WELL Locationr� Y5-7 YQu tt i C--76 IC , Cross Street Val t0 f D. city o cV zip S 6 Parcel# <br /> PROPERTY Owner ROIoeY1 RA50o Address o�6yS7 .S, 9,4l 0 J 'Citly1 I 71p '?MPhone a 636-oZIll <br /> C-57 Contractor TGC Address�ML>57 & L-A ISon W4/v City S1"66nZi, ��' i J hone A/� / <br /> Consultant/Sub Contractor &E Address 1/Q�S .A/•(NNI[Son Y4City City 9V 425 Li a ? Phon 6) V IWG <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDRQPUN H, HAND-AUGER OTHER`) 0 DESTRUCTION(choose type below) <br /> )OOIL BORING# Y� -P -Zo y 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> `Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �,/A <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0" MULTIPLE CASINGS?0 YES �'R0 WELL CASING DIA;/"" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS17(A TYPE OF CASING: 0 STE L 0 PVC 0 OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL Cn I rr C TREMIE TYPE TO BE USED: 0 AUGERS -VHOSE <br /> 0 AIR SPARGE xPUSH POINT GROUT SEAL PUMPED: p Yes ',RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 1S-;S' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? &JA(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: "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." Contractors hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.' <br /> THE APPLICANT/MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed /LG- 1A^'l.C/� Title ��0 /57( Date <br /> $rlGh /"ri I,nG., <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY �l <br /> Application Accepted By CV>^^^#-�t Date Issued_ Q/2-&000 Area .61 <br /> Grout Inspection By Date 8 Final Inspection By Date <br /> Destruction Inspection By C Date <br /> COMMENTS I CONDITIONS: CSA <br /> t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o _ _ IVA. APt 41400 OoZ 3 P 3 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />