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panvrELL PERMIT AP :aATION FORM FM I` py <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAY Q 52000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> crd`4IRONi1AENTAL HEALT�4 E. Weber, Third Floor, Stockton, CA., 95202 J � <br /> PERMIWSERTCES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> \pplication 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 <br /> /Titlee,,/Chap rr (9-11115.3 and the Standards of San Joaquin County Public Health Serrvices, Environmental Health Division. <br /> YELL Location l�7"( I )`r ' l�F(�f'� qJ Kp1-Cross Street Cit -� (�2 Assessor's <br /> ) � V Y ZiP�Parcel# <br /> 'ROPERTY Owner/In/ Zdy'/!�'I-Tj/j-h Address P ' G �G�.��B <br /> TJCity 5yr}�4Phone _ <br /> �L <br /> -57 Contractor <br /> WTyZkW� Adtlres5&.33 pp1/443 / <br /> 72 7(- <br /> C hon # <br /> :onsultant/Sub Contractor&—] f Addresity1 -7j <br /> / b <br /> 3IS Coordinates:X ,Y ,Township Ran e <br /> 9 Section <br /> NORK TO BE PERFORMED <br /> j<IEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') <br /> OIL BORING# OpESTRUCTION(choose type below) <br /> WELL#�_ , r J /�-7, / 0 OVER-BORE <br /> Other: f �IAIV 1 / O PRESSURE GROUT <br /> �OMMENTS: <br /> "YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE rl MULTIPLE CASINGS?DYES B/NO WELL CASING DIA: Z- <br /> 3 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> ]VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> J AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Dyes �[kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ]SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH IZ56 f!�fA OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ] <br /> OTHER-_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: MiAlt 1-40 <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: "1 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 /> THE UNIIT� IV INSPECTOR 48 WORKING HRS IN ADVANCE� (;/FOR ALL REQUIRED INSPECTIONS. <br /> Signed x V1,(.(i(i� �`1(..641E� Title/Company /Fc— 6y62 <br /> W I�(� . �I TTLO� <br /> Print Name i Date <br /> SEE SITE-MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY q �/ <br /> Application Accepted By Date Issued Area (a <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I COND NS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES PEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v 9682 2 f <br /> 1/18/2000 <br />