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APPLICATION FOM UNIT IV <br /> WELJERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-E:HD) FILE �({�OP <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 f/� <br /> (209) 468-3449 <br /> San Joaquin County OreveloprmentpTitits, Chapter 31115.]and the Standards of San Joaquin County Public Health Services,Environmentai Health[)!vision. _ <br /> :HELL La:atfan�+rV4 DT /off W"I©�� Cross Street Irl ✓GS Ci CSIOCKty- L Assessor's <br /> u l: ty p 5%0/ParWh* j}S-IJf50-0504 <br /> PROPERTY Owner 0�' 15f0 k7`'D7i1 Address VCvi�h[✓J City CStDC 4fo"Lp9�/ Prone# q 2 /6 <br /> C•57 Contra CH?r1 Nr�-f� Address. �SdS fFr✓04v�' D✓City %?e���'< '�°9�Lico Pf aa9-3317 <br /> Consultant lSub Contractor� ddress -I3(S'/•>,� '.-,c.n,t cify `�YecfK{w�ticJf g/2-26? -7 -Z <br /> GIS Coordinates:X ,Y Township Range_ Section <br /> WORK TO BE PERFORMED <br /> BORING (CPT.GEOPP.OSE.4YOR02UNGN.-HAND--AUGER OTHER-) Q DESTRUCTION(choose type below) <br /> a SOIL BORING# Q OVER-BORE <br /> 11 WELL# KP- BA-1 p PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE _J t ,.M'ULTIPLE CASING.37 a YES C O WELL CASING Qlk <br /> B EXTRACTION a AIR HAMMER/DRN � <br /> EN CASING THICKNESSv DPE OF CASING: Q STEEL ZPrJC Q OTHER: <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL­22 TREMIE TYPE TO BE USED: o AUGERS aF*oSE <br /> a AIR SPARGE B PUSH POINT GROUT SEAL PUMPED:Ar'fen o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 25 I rOOLTEO TRAFFIC BOX or o STOVEPIPE <br /> a OTHER: fl OTHER CONDUCTOR CASING PROPOSED? (it YES,:ist specifications hare): <br /> 75/ � <br /> COMMENTS tv2f1 W'ril ht' l0« O �'L10'� � a- <br /> S0 't rI't r,C S'f CO✓NP✓4 <br /> UPS l� VG o{- �2 tJ. J✓}5 K'%)irfX / 5lyc, t �1 [P✓,141=tG / (!�-iv ✓ 1✓'. A ✓n"t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the wont toil be done in accordance with San Joaquin County Ordinaries, State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I cer'ufy that in the performance of the er" <br /> for which this permit is issued I sha0 not employ persons subject to WORKERS'COMPENSATION Laws ofCalifornia." Contractor's hiring or sub <br /> contracting slgnatune certifies the following:9 certify that in the periwmance of the worth for which this permil is issued,I shelf employ persons subject to <br /> WCRKERS'COMPENSATION Laws of Calfforma.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Q-r/ Tide Y I&g 1"R-" Date -�'I I I C/ <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED_ <br /> DEPARTMENT USE ONLY - <br /> Application Accepted BS' �- Oate Issued �- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AIDS <br /> PE CODESFEE INFO AMOUNT REMITTED CHECXWCASH RECEIVED BY DATE PERMITlSERVICE REQUEST NUMBER INVOICE <br /> 2404! (till J ti I r <br /> om <br /> i UMT N-6/23/99/sign bkpg/MI <br /> 6ti4''-89V(60Z) <br /> 4 Z0Z96 `'VO `UO1AOO;S `1oolj P1141 `-lagaN1 3 I70£ <br /> I <br /> ((3H3-SHd) NOISIAIC Hllb'3H 1V-LN3WN02iIANEi <br /> S301nb3S H11'd3H CllfiCld A1N[lOO Nb'Of {� <br /> Al LINn V0:10=1N0IJ-V3IlddV lIW2i3d 713M <br /> � i - <br />