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y WE - PERMIT APPLICATION ]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 � <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 wit'h'`� <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Di'visron. <br /> WitIELLLocation AL414 W. tIS4 S:± . Cross Street C"A x -n City �s-_ y +r'�_Zip c�S�� Assessor's l <br /> b Parcel# .'s <br /> PROPERTY Owner clf' -"- G IZI ` o Address-VA-1 i W• 0'-- St City r qc Zip S 3'I Phone# Z,09- S 3 S-Z42-1 <br /> C-57 Contraclor`q*VAI 4 C^� <br /> V \\',+moo Address nb I-{t1,� ^�Cityr �slc�o.. Zip $ ql I_ic# �Phone# �1�0•�7 1 l iOI <br /> V I <br /> Gonsuitantl Sub ContractorAddress `k\ kar 4 City�V �� Link Phone# ag-S$2=6';7,� <br /> GIS Coordinates:X Y Township S Range S G Section 2- <br /> WORK <br /> WORK TO BE PERFORMED <br /> a NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type be <br /> d SOIL BORING# $OVER-BORE 3 t►.w <br /> "Other: Q WELL# PRESSURE GROUTSVV�v, <br /> COMMENTS: A 0. of&-c'V'4 �k, S i 1►-.0�� W Owl .y.� i- E O+'rt.S o ma+L� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?©YES o NO WELL CASING DIA; <br /> EXTRACTION it AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL Q PVC a OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br /> .p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> a BOLTER TRAFFIC BOX or 0 STOVE PIPE _ <br /> Q OTHER: fl OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): _s <br /> COMMENTS. p S r D --x <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: "l certify that in the performance of the wark <br /> for which this permit is issued,f shall not employ persons subject to WORKERS'COMPENSATION Laws of Callfomia." 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, l shall employ persons subject to <br /> WORKERS'COMPENSA TION Laws of California." <br /> ,,._ ...y. ..._--_ <br /> .r � <br /> I� •`� wg­ <br /> Signed x Title C o" Date_ <br /> x - <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 5 I s 1 d o <br /> �1M DEPARTMENT USE ONLY <br /> Application Accepted By r Date issuedArea <br /> �- q <br /> [ <br /> Grout Inspection By Date Final Inspection By Date ; r-.1 U, <br /> Destruction Inspection By Dat <br /> COMMENTS I CONDITIONS: m yY1 W r✓t! p —b-e- ce �U os Y Q <br /> M rnW Mw(, W r <br /> ACCOUNTING ONLY: AID# I <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST* INVOICE <br /> Co o <br /> 3 5. ::l.:.:..........__...._: <br /> l � <br /> d� <br /> 0 <br /> �`S <br /> 1 <br /> __...... n.. "-"_rra. <br /> UNIT IV-5/23/99/sign bkpg/MI <br /> Z: d WObA wcf9E:E 6661-GZ-c <br /> 4 <br />