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WEAERMIT A? ATION FOM UNIT IV <br /> SAN JOAQUIN COUNTY PU LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA.,(209) 468-3449 fitt <br /> NON-REFUNDABLE PERMIT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q�/_ <br /> Aoolication is hereby made to San Joaquin County for a permit to construct andigf install the work described. This application is made in compliance oath Z 1� <br /> San Joaquin County Development Title, Chapter g-1115.3\ s SVeeeand the Standards of San Joaquin County Public Health Services,2nvwonmental Health Division. <br /> WELL Location k6,,k6,,,rive So or=� CrosC Assessor's <br /> . � aY roil LP Parcel# /4.3-066-15 <br /> PROPERTY Owner }&NNerr CANsuramW Address 23335;^, -,\1AU*4 City -A-Z-1- Zip 94103Phor <br /> C-57, Address 3233 FiST Ciry2,-..ao/"`ar. Zipj5742 L.iCt CSSIq' pdone#9/6.-1.38-7274 <br /> Consultant/ an[raC.or Address 2444 N9w».,5- 215 City t .v�Lidt Phone#$�5-ZL¢-TS3.S <br /> r� <br /> GIS Coordinates:X 37-55' Y rZ IO 19 90 r .Townsnip T 1 N Range R fo E Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, ND-AUGER.OTHER-) Q DESTRUCTION(choose type below) <br /> $SOIL BORING# IeAR-Y 0 OVER-BORE <br /> "ELLX ' —+ Z L 0 PRESSURE GROUT <br /> "Other. r <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS M4_7 <br /> �, <br /> ONITORING HOLLOW STEM DIA. OF BOREHOLE "'`6r� MULTIPLE CASINGS7 a YES ,SNC WELL CASING DIA: —yd�r <br /> Q EXTRAC710N AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: G STEEL ;'PVC 0 OTHER: T <br /> Q VAPOR X MUD ROTARY DEPTH OF GROUT SEAL 6+f Sc' TREMIE TYPE TO BE USED: o AUGERS )1ZHOS'c <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: XYes p Nc (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTHn170 Q BOLTED TRAFFIC BOX or f/``�5T'OVE PIPE <br /> Q OTHER: J <br /> 0 OTHER CONDUCTOR CASING PROPOSED? .Jct (it YES.list speahcations here): <br /> J',--7-b'5 <br /> COMMENTS: 13o2,�a r_. . !_- LOG, �o /'fI t/ 7-2- <br /> 1-3p I <br /> Z/301 -i r 27t t Z7= 25' i �+ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I nereoy certify that I have prepared mts application and that the wont will tm done m 2==nce w1U1 San Joaquin County Ordinances, State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agents signature certifies the fallowing: "1 certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subi to WORKERS'COMPENSATION Laws of Califomia." Contractor's hinmg or sub- <br /> contramirl signature certifies:he following 'I certify that in the performance of Bre xork for wtuct;this pencil a iscuee. 1 snall employ persons suo/ect to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICA T CALL 48 HRS IN ADVANCE FOR/ALL REQUIRED INSPECTIONS q <br /> Sgnedz �.___ Title_7+affc.r LXstOo,5._ Date / <br /> SEE SI NP NIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 9 /r <br /> Application Accepted By Date Issued D O L Area Lb <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: ! AID# FACS <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED ! CHECK#/CASH RECEIVED BY I DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ! O/98o� I <br /> C-5r' LZCEL�TsC 4� EQ1k1�SSIIf�FS) f}.RK s } pE <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> Gl- <br />