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WEA'. PERMIT APPLICATION rJRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C E I <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NI) 1999 <br /> (209) 468-3449 <br /> is'd <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 /> S,ZD Assessor's <br /> WELL Location R76��/.D4yrs 1217) Cross Street-&r/JAW City 5�z� Zip9 q Parcel# <br /> PROPERTY Owner_<C/ Nle4oxw Address-M lu.Drn+ts City Zip��0`� Phone#40 t- 161t4 <br /> C-57 Contractor r/_S[4 6t/1///!/lf je./Address .Si�]Le/1Si4GCCity �ZipLi��Phone# -112-3510 <br /> Consultant I Sub Contractor_a ilovxd zcrc, Address VONn 4 City.iESexd(Au Lic# Phone#Ug-CIW? <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> /NEW WELL BORING CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 'SOIL BORING# I S 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: 44*0 4, 5 noy, S <br /> TYPE OF WELL -INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 luck MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .30o te+ _ _TREMIE TYPE TO BE USED: GAUGERS 8-OSE <br /> 0 AIR SPARGE GUSH POINT GROUT SEAL PUMPED: 0 Yes '0'\No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING 0 HAND AUGER APPROX. BORING DEPTH 3c� c-k 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (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: "1 certify that in the performance of the work <br /> for which this permit is issued, I shalt 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, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws f California." <br /> T PLICANT US WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title ?-a �Vx3 Date !�2� 0C> <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 1- Zo-zztr�o <br /> DEPARTMENT USE ONLY <br /> Application Accepted By I— Date Issued Area <br /> Grout Inspection By � �o�-..,_ Date ct 1)106 Final Inspection By 0---\ Date 1 O <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Asa <br /> Al C301.00 clot � $; 3f cDsg# 00X3F50 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />