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4 WELL PEWMIT APPLICATION FORK° UNIT IV <br /> 1 <br /> .SA,t4-JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> r %. Weber, Third Floor, Stockton, CA., 95202 <br /> �� (209) 468-3449 <br /> I# <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 /> an Joaquin County Development Title,Chapter 9-1195.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> P1460- <br /> Assessor's <br /> I TELL Location_ i f Erle!pri,5r f' 60- Cross Street ) 'he At -� '• City Trai CV Zip Parcel# <br /> Il � h. <br /> ROPERTY Owner f� rr_7 �rziYf !Cjp,,_ Address t' ) k t City a Zip L / P (,),A-hone# �S �- 1h <br /> -57 Contractor f•1 G� _ Address �%Q� r�'►r�c1 �vu ity r X Zip 9V-o]_/Lic#�Phone & <br /> onsultant l Sub Contractor Mrr Address_yfi0�Al,(.c.lt5/on1 City Phone 9`I t j0"fG-'E' <br /> t <br /> t IS Coordinates:X Y Township .! Range Section <br /> i <br /> 'ORK TO BE PERFORMED i <br /> NEW WELL I BORING (CPT,GEOPROBE, HYDRO UNCH, ND-AUGER,OTHER') E DESTRUCTION(choose type below) <br /> F SOIL BORING# �`5- - j OVER-BORE <br /> p WELL# T PRESSURE GROUT <br /> )they: ' <br /> L OMMENTS: <br /> 'Y <br /> L YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLES t MULTIPLE CASINGS? YES JO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS^TYPE OF CASING 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C-t, -if-C TREMIE TYPE TO BE USED: 0 AUGERS 'NHOSE <br /> AIR SPARGE ,`PUSH POINT GROUT SEAL PUMPED: 0 Yes .gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 501E BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? � ' {if YES, list specifications here): <br /> ip <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> iereby 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 /> )d Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the;following: 'Y certify that in the performance of the work <br /> ar which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or Sub- <br /> mtracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employpersons subject to <br /> /ORKERS'COMPENSATION Laws of California." I� <br /> CALL THE UNIT IV INS ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> igned x )w' Title/Company <br /> JA`/� ���► Ceti 05l'S� <br /> rint Name (�1 f` ( f u't ✓� Date7--7- <br /> SEE <br /> - --� <br /> SEE 'SITE MAP. IN UNIT_ `[V: WORK, PLAN:-DAT <br /> DEPARTMENT USE ONLY I� <br /> pplication Accepted ByL:_ vz�w� r/` —Dale Issued-! '7- i U cl- - Area 0_7 e <br /> c <br /> rout Inspection By Date Final Inspection By Date <br />` estruction Inspection By <br /> OMMENTS i CONDITIONS: <br /> 'r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE i PERMIT I SERVICE REQUEST# INVOICE <br /> 351 $`r— g z — tefto Cry ��ivla a335! <br /> 1/18/2000 <br />