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WAL PERMIT APPLICATIOIFORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (" PHS-EI 7 <br /> - 304 E. Weber, Third Floor, Stockton , CA., 9520 <br /> (209 ) 468-3450 ) UN 0 31999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,��LTF, <br /> G VIPO �'�ENT~'- � r+�C <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appst t r tg[gin'pf f;95ith <br /> San Joaquin County Development Tide, Chapter 4-1115.3 and the Standards of San Joaquin County Public Health Se rvi ESiY onr( ental Health. Division, <br /> 517 Gtl2� marf- roAssesspfs <br /> WELL Location Crass Street Cit//y �J��Cd� !.�`--��, arceMF <br /> PROPERTY Owner C� Address .� 7 L�.� • /r�•P,rVtcYrlCityip��C��hone# 6 ? <br /> j A�1fue.E �� dt.�z ty _ <br /> � � <br /> k C-57 Contractor dress �W1�Ci Phone# `/�7 /35 & <br /> Consultant ub Cpntracto .iddress,�}� �-T-+'�u�,�itvLiC�oZ �P Phanl(o s <br /> ppp GIS Coordinates: X. Y., Township Range Section <br /> WORK TO BE PERFORMED <br /> A<�EW WELL / BORING ( CPT, GEOPROBE. HYDROPUNCH, HANO-AUGER. OTHER') a DESTRUCTION (choose type below) <br /> 13 SOIL BORING # a OVER-BORE <br /> a WELL # a PRESSURE GROUT <br /> -Other. <br /> COMMENTS: <br /> I TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFI ATIONS <br /> ,�ACNITORING �.OLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? a YES a'('O WELL CASING DIA: Z „ <br /> a EXTRACTION a AIR HAMMERIORIVEN CASING ,HICKNESS TYPE OF CASING: a STEEL )'PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 160 ' TREMIE TYPE TO BE USED: ArAUGERS QHCSE <br /> :] AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: )rYesNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 302 ) <br /> ,] SOIL BORING a HAND AUGER APPROX, BORING DEPTH O I OL TED TRAFFIC BOX or a STOVE PIPE <br /> a OTHER: CONDUCTOR CASING PROPOSED? ( if YES. lis: specifications here): <br /> `COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> 1 hereby certify that I have prepared this application ana that me work will oe done in acwrcance with San Joaquin County Ordinances, State laws, and Rwes <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the per/ormance of the work <br /> !or which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Con[ractors :tiring or sub- <br /> contracting signature certifies the following: 01 certify that in the performance of the work for which this permit is issued, / snail employ persons subject to <br /> YNCRKMWS COMPENSATION Laws of California. ' <br /> t �J l/ //TH� E APPLICANT MUST CALL 48 HRS IN ADVANCE FOR /ALL RE IRED INSPECTIONS , <br /> Signed x �.0 11 .0 X.��/ ,71 A Title (� Date <br /> SEE SITE MAP IN UNIT IV WORK PIAN . DATED -/ - � 8 <br /> /� DEPARTMENT USE ONLY rf <br /> i Application Accepted By 2.n �r f::_ Date Issued %n - ? — rl 5 Area /,1 7 b <br /> Grout Inspection By J Date 61iG 'r`G�7/tel Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: I �, /p p ,sr' Gt+ (,t// GLte. SG(p_E.. <br /> ACCOUNTING ONLY: AID# -AG. <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC #/CASH I RECEIVED BY DATE II PERMITISERVICE REQUEST NUMBER INVOICE <br /> 35 v / S9 ��/ � _ �S //`J 3 � CJ 64/f7 <br /> UNIT IV - 5/99 /Mr i" t/Gfit/ l �t <br />