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WEbe PERMIT APPLICATION MRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Po-da ` ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for i permit to construct and/or install the work described. This application is made in compliance with <br /> San Jo Quin Countv evelopment Title, Chapter 9115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Au.(15 eJw v! Tr'Io9,Nrc^/ o ® HcA^/T,-A PAD G <br /> WELL Location � / q Cross Str4e, AP;iAL /1vi• IS �/ Assessor's <br /> pp City LOn i Zip � /� Parcel# p55'/5o-L5 <br /> PROPERTYOwner_/�rLNAAo P?,,K;DE5 Address (047 1 COP,4ALF1'C City Ip0= Zip 9,�?yaphone ZO`' °Jb�yj�O <br /> '' 1 +/6 4N-H, <br /> C-57Contractor WEST NA7- M9 I Address-VaN City CRD[..LAZip 57V�LSSYr)71 icitPhone# LII(o ,38 R61 <br /> G F o c uvr <br /> Consultant/Sub Contractor_AJv ANLED £ny'mrP�t^Zdressyou45 A/, VJ ilS�n City S- -LKL.c 1Lic#I6bcL27 Phone# &q 4b7/oN6 <br /> GIS Coordinates:X , Y ,Township 30 Range J Section <br /> _ <br /> WORK TO BE PERFORMED <br /> ANEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> (( �\ 0 SOIL BORING# <br /> SWELL# M W- " 0 OVER-BORE <br /> 'Other: / 0 PRESSURE GROUT J;�, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING LLOW STEM DIA. OF BOREHOLE L ` r <br /> MULTIPLE CASINGS?O YES WELL CASING DIA:,_ V <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS Sc rl @D v1 z y o TYPE OF CASING: O STEEL�VC O OTHER: <br /> VAPOR Sv PF.LK 4a <br /> O O MUD ROTARY DEPTH OF GROUT SEAL 4 �.c 4 65(.TREMIE TYPE TO BE USED:-SUGERS OHOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: &Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH -?Q 1+U ` BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ^,o (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: "/certify thaf in fhe performance of the work _ <br /> sub- <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." 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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> JHE APPLICANT MUST CALL 48 WORKING HRS IN AD NCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x � Title r QL T GPO ' )r'Date03 <br /> 0 <br /> SEE SITeMdA IN UNIT IV WORK PLAN DATED: a I/ <br /> DEPARTMENT USE ONLY 13 <br /> Application Accepted By Date Issued 3-)13- OVrea `--�+ <br /> % <br /> Grout Inspection By Date Final Inspection By A <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE[ :ntO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3` 3,Q) 3^fD 22( <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />