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WEP PERMIT APPLICATION F _ RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RUD 23 rin 1 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 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 with <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> f ,,f (� .r Assessor's <br /> WELL Location 35% ," 1✓T. Cross Street [V/G�tfl- �• n,City G Zip Parcel# <br /> PROPERTY Ownerl05�t4 �1M�l�1LLIG� IP �_�Addd;ries//s_it?'SS]A;1TClre���a45 �l Ci �� Zipq 6 Phone# 5161A106:12 <br /> C-57 Contractor Address//l7v 1Ot�2� I f _C�ityp � Ke 1Ziip�Lic#gKL6 Phone# Z <br /> r i&( Address70��Q0�APytD�7TK,I�7�F+►�Cih J�t+(I�r� ic#R&y30-fPhone# 14i —I6l <br /> Consultant/Sub Contractor �'iLpK� I�D�ttktW <br /> GIS Coordinates:X Y Township !V Range 6!� Section b <br /> WORK TO BE PERFORMED <br /> g i4 W WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> �J 0 SOIL BORING# 0 OVER-BORE <br /> O VYELL# 0 PRESSURE GROUT <br /> 'Other: Z, ! cujJcc � <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 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 /> )KOTHER:" O OTHER 60- _ CONDUCTOR CASING PROPOSED? (if YES, list specifications here). <br /> COMMENTS:--L— — <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: "I certify that in the performance of the work <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, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> TH PLICANT MUST <br /> cCALL <br /> L48 WORKING HRS IN ADVANCE FOR <br /> /ALL <br /> /REQUIRE D IcN PECTIONS. <br /> Signed x (( 1(.t.�T Title (p r1toi1 4,S'f� ej 1x0/ Date O 2 2 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: Nl" lu�f� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Date Issued 0.-kI I Area—ca �— O <br /> Grout Inspection By Date I Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o� � � 6027 2? <br /> C-57 LICENSED CONTRACTORMUST SIGN LICENSE&WO RS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />