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vvt �MwPERMIT APPLICATIONJRM UNIT IV <br /> SAN JO <br /> AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95Z02 <br /> (209)'468-3449 <br /> Application is hereby NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Y mads to San Joaquin County for a permit to construct and/or install the work described. <br /> San Joaquin County Develop:nent Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public H <br /> This application is made in compliance with <br /> WELL Location 7 Gu i IvLSr 7t Health Services,Environmental Health Division. <br /> Cross Street r i fN". City Assessor's <br /> PROPERTY Owns , Zip 7� Parcel# 3S-» —14,0- 11 <br /> Address-3�yLOR �iarrrlsv P',W,* <br /> C•57 Contractor At•IVA✓ EX /i�pp ddress 3 �,t,f r Z,p-=-- _�hone# <br /> Consultant/6ab-ate r+�s <br /> city,5.&.0 ; Lic#�1.Z�?! <br /> rlkth y/� V Phone# ZS 'os"'�7 <br /> Address J <br /> GIS Coordinates:X1.7 3 9 G�.f Cityf!�-fa Phone#S✓0 6b a7z_7- <br /> Y yy� / S' ,Township 7R'A'W T' <br /> �R TO 13E P�a�no..�., Range S Section_ ? <br /> �.GEOI�ROBE.HYDROPUNCH,HAND AUGER,OTHER-) <br /> Q SOIL BORING# <br /> -Otfre0 WELL AESTRUCTION(choose type below) <br /> r• # <br /> R <br /> COMMENTS' �J�PREUUREEGROU�T <br /> TYPE OF WEL <br />-- �INSTA�LLATIQN�PE�CN8TRUCTION SP�EClfATIONS <br /> MONITORING 0 HOLLOW STEM <br /> EXTRACTION DIA•OF BOREHOLE L ~ MULTIPLE CASINGS? YES <br /> AIR HAMMER/ORtVEN CASING THICKNES y� 0 O WELL CASING DIA:�'p <br /> 0 VAPOR 0 MUD ROTARY SEAL TYPE OF CASING. 0 STEEL VC <br /> p AIR SPARGE DEPTH OF GROUT SEAL ,Jk� D OTHER:_ <br /> 0 PUSH POINT GROUT SEAL PUMPED: Yes TREMiE.TYPE TO BE USED: 0 AUGERS QHOSE <br /> O SOIL BORING 0 HAND AUGER 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> APPROX.BORING DEPTH .Z D <br /> 0 OTHER:_ t1 OTHER 0 BOLTED TRAFFIC BOX or <br /> CONDUCTOR CASING PROPOSED? 0 STOVE PIPE <br /> (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCRGA <br /> hereby certify that 1 have prepared this�'Ncatron and that the work will be done in accordance with San Jo ACHMty 'T" PERMIT$ <br /> nd Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following; '/certify Nrat In the performance of the worn <br /> P Issued,I shall not employ State laws,and Rules <br /> orttracting sk,Inature certifies the followi p y Persons aubJect to bYORKERS'COMPENSATION Laws of Ca►ifh8t in <br /> Contractors hiring or sub- <br /> VORKERS'COMPENSATION Laws of� �that in the Subiec t o O the work for which this <br /> THE Permit is issued,1 shall employ persons subject to <br /> PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> SEE ITE MAP IN UNIT IV WORK Date_-__ _�J1i"-' r <br /> PLAN DATED <br /> Plication Accepted By DEPARTMENT USE ONLY <br /> out Inspection By Date Issued <br /> struction Inspection By Date Flnal Inspection By <br /> Dat <br />�MMENT3/CONDITIONS: Date <br /> CCOUNTING ONLY: AID# <br /> FAC# _ <br />?CODES FEE INFO AMOUNT REMITTED CHECKNCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />,' LICENSED CpR M.T rV-6/23/99/sign bkpg/Mr UST.SIGN LICENSE&WOE'C OMPENSATION I <br /> DEC I <br /> I-AR.ATION <br />