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5_03_1009 12:49PM FR4 0 P. 3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weber,Third Floor,STOCKTON,CA 96202 <br /> (209)6683450 <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 nd the Standards of San Joaquin�County Public Health Services,Environmental Health Division. <br /> RSc� ` s � � � �l N/ >�' ci1✓}l Assessors p <br /> WELL Location I,A /(Fr�--l.�,. ( Cross Street I1 rrity k u 1t4 Parcel# 1 1* `W 0 <br /> PROPERTY Owners Name r��,(H+-��7 Address. 5�10 KEJ"L�- I)'v.. I Phone# 770-53LZ 9 <br /> Contractor2C/ <br /> M� n� CY/�I Address2ZE- M- UJ)kE. 201 Lic# Phone#�CS-Q6-2"Z1Z�- <br /> Sub Contractor �eST �7TZ 14-7 - Address Lic# Phone# <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE, YDROPUNC HAND-AUGER, OTHER-) O DESTRUCTION(Choose type beiow) <br /> OIL BORING#_ �6�-i O OVER-BORE <br /> 'Other. 0 WELL# 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE S MULTIPLE CASINGS?fl YES 0 NO WELL CASING DIA:_ <br /> O EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEcPL 'f> TD TREMIE TYPE TO BE USED: 0 AUGERS OHCSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH L6.� O BOLTED TRAFFIC BOX or p STOVE PIPE <br /> O OTHER: CONDUCTOR CASING PROPOSED? (if YES,list specificavons here): <br /> COMMENTS: D 'mss owY U <br /> C <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. Home owner or licensed agent's signature certifies the following: 'I 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 Caldiomia.' Contractors hiring or sub-contracting <br /> signature certifies the following: ' certify that in the performance of the work for which this permit is issued. I shall employ persons subject to WORKMAN'S <br /> COMPENSATION Laws of Cali ia.' THE APPLICANT MUST CALL 48 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)468-3450. <br /> Signed / Vy T41e 5f— 6EDL.06)ST- Date 6601911' <br /> � I <br /> I 1 Al <br /> I <br /> II ! I � I II III I I <br /> v�1 l <br /> DEFIARTMENT USE ONLY O/1 Ct q <br /> Application Accepted By f-C. c ( QDate Issued /I Area <br /> Grout Inspection By i - Date !Final Inspection By Date <br /> Destruction Inspection By 'G' Date �i f L <br /> COMMENTS: .�( tliti S r,t"C' rS fJ L•�'l� • 'r/" <br /> C o, r bcn fF Fcr tit, (r il4kr w, l i n g Dov 6ft) <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECKWCASH I Rf C D BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 9GI 09.40 15-13 CIcq' 5R9 (J' I9 c(C5 <br /> UNIT TV/10-98/MI 7/�'T <br />