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Vv LLL PERMIT APPLICATION .`ORM UNIT IV <br /> SA14 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PH 1, '"N E IV E Fu <br /> 304 E. Weber, Third Floor, Stockton, CA., 9k'62— <br /> (209) 468-3450 J U L 2 3 1999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ONMENTP+L HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi4Da�p�l�Idn� >!de'1'tlZd once with <br /> San Joaquin County Development Tale,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> WELL LocationU l 5. L h[dlot Avg Cross Street SO►'1C�' City Zip Parcel# 107-0d-03 <br /> NcxKe�m t c l.lt�. <br /> PROPERTY Owner Pep,* <br /> ep,, 5imoo e-04 ;Wflarewnrck)-wkQ City 57cpC' 00) Zip �5D Iq Phone#,A9-4W-,2�c <br /> ��)�uc�CcvCCc�nu:;n.ritr�+Fi,� 3315- '-, 1,i�/o,.,a /roc, Sfc 117 9�lpU� <br /> 0-57 Contras" br / Address Ci`t-y N /; Zip .Jc# Phone# <br /> Consultant/Sub ContractorQi�la�1tP�l}�FYI UI YbY1fNeYl law I Address ybCS►L`.I/}►ISp;�L+�t 4 CitySL KTI) Lim Phone#y�C9 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Vl E&WELL BORIN (CPT(GEOPROB HYDROPUNCH,HAND-AUGER, OTHER-) a DESTRUCTION(choose type below) <br /> 1] RING# -�/—S Q OVER-BORE <br /> a WELL# y PRESSURE GROUT <br /> 'Other. <br /> CCMMENTS: <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS { <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?p YES p NO WELL CASING DIA: 5`J <br /> ] XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS G TYPE OF CASING: a STEEL a PVC a OTHER: <br /> VAPORp MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS C HCS <br /> ]AIR SPARGE GUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> *OIL BORING a HAND AUGER APPROX. BORING DEPTH t5"- 2,-) / a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> nereby certify that I have prepared this application and that the worn will be done in accordance with San Joaquin County Ordinances, State Laws, and Rwes <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.1 shall not employ persons subject to WORKMAN'S COMPESSA77ON Laws of California." Contractors 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 /> WORKMAN'S COMPENSATION Laws of California.' <br /> THE APPLICANT MUST C 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x / G Title I /colo/ �r��is� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED (y 99 <br /> DEPARTMENT USE ONLY <br /> Apolication Accepted ByDate Issued 7— lam'S Area 079 <br /> �• <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK ASH I RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBERINVOICE <br /> S R# d 3v �17 , <br /> UNIT IV-5/99/MI <br />