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0P. <br /> 5-03-1999 12:1C9Pt✓I FROM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 704 E.Weber,Third Floor,STOCKTON.CA 95202 <br /> (209)468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 9-1115.2 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> q.SQ 4 Z2, Ct1Y1 t klN `'� lj 6T. PtGt� sessars 11 210 6.3 <br /> WELL Location PF <br /> ! Cross Street Ll� Ci �N Parcel# 1 17 <br /> PROPERTY Owner's Name SA-MES TF�SS Address 340 SEKE TEVIFUh� phone#T/6-538-ZA <br /> Mart CAS �DD'4 sTE zoo <br /> Contractor Address p22Z E; C,A�.'Rtl.te C 20 Lilt Phone# U'QS-962-2.12Z. <br /> Sub Contractor CSP-EGG (�-SITS t l�C, Address .1 b nwa Lic# 6G71,Lf 6-7 Phone# Q27 '313-Sgt <br /> J WORK TO BE PERFORMED <br /> ` (P 6 <br /> "KNEW WELL I BORING(( ,,G PQfiE.HYD�CH,HAND-AUGER.OTHER-) ✓ 0 DESTRUCTION(choose type below) <br /> '\ Q SOIL BORING# Q OVER-BORE <br /> Q WELL# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES ONO WEL_CASING DIA:_ <br /> Q EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS QHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER APPROX.BORING DEPTH_a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: CONDUCTOR CASING PROPOSED? (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,Slate Laws,and Rules <br /> and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following:9 certify that in the performance of the work for <br /> which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California.- Contractor's hiring or sub-contracting <br /> signature certifies the following: 'I certify that in the pe formance of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S <br /> COMPENSATION Laws of C filomia.' THE APPLICANT MUST�C�ALL 48 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION AT(209)468-3450. <br /> Signed x �I de 1^' I !t"-� Title - (n����b��l Date V <br /> -L-L 4+ <br /> bEPAR Date Issued ENT USE Y <br /> � �� Area <br /> Application Accepted By — Gi <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By Date / <br /> COMMENTS: P1" I i .�" `14 N /1C) \"� �v <br /> iS �VYL ,o� R FC L� 7 - / 7U <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IV/10-98/MI �rX I1r <br /> �^ D 1 <br />