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VVE�--L PERMIT APPLICATI " R T3w' IC/`J� <br /> Li <br /> r.� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERBES' <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) AUG 16 1999 <br /> ggp IY304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> �tltl� (209Y 468-3449 ENVi'RONNMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUEDarRMI T /1 SERVICES <br /> Application,s hereby made to San Joaqui Coun y fora permit to construct and/ar install the work described. This application is made in compliance with <br /> San Joaquin County� ntrT,iye, 15.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> o L { �i,,((// rK W.(3Ywn,-t Li,1c Assessor's <br /> WELL Location or i s nT ij 4yGC� oy+ Cross Street Bond City T�� Zip 8537.0Parcel# - 70-36 <br /> PROPERTY Owner g clrt Mol+lf #-t e(L� Address 13WO w-Graot Lia U City -TV--0xt4 Zip FJ 3-1(o Phone#101-$37--1328 <br /> C-57Contractor "—((-Millin uW oli,M a Address1!l0OOf fI^L,} City �twte Zipl�ftff Lic#k&387Phone#5D Z3�`��i76 <br /> Consultant/Sub Contractor--&fflAiXtX 0)6$An 5 JoAddressZlol V)etoyt�y) (2241 1140 City6aV-ta+14( Lic# _— Phone#510-/nf03-'{I00 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> ,<NEW WELL/BORING(CPT,GEOPROBE, DROPUNCH, HA -AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORIN # OVER-BORE <br /> O WELL# <br /> 'Other: O PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES )J�NO WELL CASING DIA:Hk <br /> O EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS &A TYPE OF CASING: (]STEEL O PVC []OTHER: WA <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> O AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' OIL BORING O HAND AUGER APPROX. BORING DEPTH I S lldt�- O BOLTED TRAFFIC BOX or O STOVE PIPERA <br /> 0 OTHER: O OTHER CONDUCTOR CASING PROPOSED? tAA (it YES,list specifications here): <br /> COMMENTS: o. (Oo q(euy\c(cyotf,C� SNMPLt -� �r�nn a fectiE�.l ItnoV1 Cmw7nl�-FiaN <br /> v <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 Joagyin 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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cahromia." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Q e0 <br /> Title (<04/S f' Date 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued �^ 1 <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: -�► 3 r E �� <br /> FACCOUNTING ONLY: AID# FAC# <br /> ODES FEE INFO AMOUNT REMITTED CHHECEC/�K01CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> .11195B - <br /> luUNIT IV-6/23/99/sign bkpg/M �.__.... 1 �TyQ ,. ... �. ] ;r` � 3,._ <br />