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-moor <br /> WE► , . PERMIT APPLICATION r")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 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <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 Divisidn. <br /> WELL Location A y-)Ik W . 11 S S} Cross Street Gh. vs rnwr`944, r-r�.c 53 Assessor's <br /> City— `� Zip I 7b Parcel# 15�• Lop_ p� <br /> PROPERTY Owner C mac,\.ho Address 1�1Z4 \n1• Crt- —T rO`��ZiP'tS S b Phane# 209- S 3 S-7 42-t <br /> C-57 Contractor`p <br /> o- vel 9 r.\\ Address 13 �,t�k�� -1 Lo 90� <br /> st- 4 b city zip Sb�ll Lic# Phone# <br /> Consultant/Sub Contractor Z` 1 4 rny\c �v l Address 91kCity�)ku <br /> Lic# Phone# Z og_S 39-bye <br /> GIS Coordinates:X Y ,Township ?-'Ci G—Range Z <br /> 9 S Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL I BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") `DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# $OVER-BORE 3 ir,w <br /> "Other: p PRESSURE GROUTS ftw <br /> COMMENTS: Q GL F Ac 0,C V�1� S 1,�Q� i W O 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C,Sp o"�_ <br /> I MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC BOTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: fl OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: Y1�on r"\ �c Q �`S o S r p <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws, and Riles <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/certify that in the performance of the marc <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sc:-- <br /> contracting signature certifies the following: '7 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject tc <br /> WORKERS'COMPENSATION Laws of California." <br /> YIiE AR CA IIIUST ?lf ) E f 'At R00Uf- I4N`$fi, f!lS <br /> G _ V 1. <br /> .... <br /> Signed x <br /> Title on Sk\�a.A-'f Date�c�.I`1 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 5) 1 s o o <br /> DEPARTMENT USE ONLY q <br /> Application Accepted By Date Issued ;l Area [ y <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: M L Yn W (yk t t f I a r'-wVA Ae OU P1 Y Q <br /> M1 Y\U1 3 V� <br /> LA-) LA) M W Io fM W41r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3S o ( a <br /> i l 1 «- 3 o6 <br /> OD q-? l <br /> crrrrc <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> Z d WOad Wd8£'6 6661—SZ—C <br />