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A <br /> W LL-PERMIT APPLICATIO�+II'RM 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 APR 14 2000 <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 <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 gSaoy <br /> Assessor's <br /> WELL Location �)U'�• �r Cly 91 Vtx• Cross Street Ruinicr iQ�vt City S+ock'�'or Zip <br /> PROPERTY Owner Vtntli S _(Dr%eeLvra Address ;Y&J W t-„ .JN UJ, gJjCityS-�a,k414 Zip cE40 Phon y -' 313 <br /> C-67Contractor A Ncl 10 �/r�r� � Address sa&D S. (i`�i ITvC. City C 1m ols Zips SY%Lic# X720 Phone#IY& Z�V <br /> Consultant/Sub Contractor / rrl L— Address L1065' • V 1156. U66y City.c4od fqi Lic# Phone(cQ1)Y(--7-/0C4 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> I(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> &WELL# A+w1 Fn,w1. Mw5-;MwW 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it <br /> 'X*ONITORING HOLLOW STEM DIA.OF BOREHOLE S L MULTIPLE CASINGS?0 YES WNO WELL CASING DIA: -P <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /1iA- TYPE OF CASING: 0 STEEL JkPVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL En4-i f'f- TREMIE TYPE TO BE USED: ;'AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes "o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH S a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? t/ Ar _(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 Califomia.” 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 /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x p TitleOma,! > Date <br /> prion rlk"'C' ) Jf <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> EPARTMENT USE ONLY <br /> Application Accepted By i D to Issued f42006 AreaZJ a <br /> Grout Inspection By Dat4 al Inspection Efy Date <br /> Destruction Inspection Date <br /> vT ­ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAIIA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT i SERVICE REQUEST# INVOICE <br /> IQ 1 r 3 5?o fly) i Et#©02 Z 4 <br /> C-57 LICENSED CONTRACTOR NIUST,SIGN LI S 'W . RKERS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg%MI <br />