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�+ w <br /> WELL(_""'ERMIT APPLICATION FCf'-*'°M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC EALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEkR FROM DATE ISSUED <br /> Vpplication 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 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> A F — Zip,52GS Assessor's <br /> NELL Location �tSD Loyr ,-s Cross Street] m � e <br /> Parcel# <br /> DROPERTY Owner bAkf F6LC9 E,e _Address 31 lett S7 FA0V_ City VlaCL4440 Zip 60 31,6 Phone# 7`i/- 44'7x` <br /> -57 Contractor 1rt "T NAZMAT Address 7Z3-3 F6r44-9 L•D 5T Cit Ccs Da�/A zipLS7 �2 Lic# 171 Phone#t&3E- 717(, <br /> p <br /> : Aonsultant/Sub CcntractorA,1* 0:) t oP,,iV,a0• Address q /tSp! .a CityS7,xk_76J Lic#6W?-27 Phone os X67-1006 <br /> 31S Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED <br /> ,�KEW WELL/BORING(CP TOPROBE, HYDROPUNCH, HAND AUGER, OTHER' 0 DESTRUCTION (choose type below) <br /> g1SOIL BORING# l 0 OVER-BORE <br /> g,WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> kUIONITORING 2 OLLOW STEM DIA. OF BOREHOLE S'W' MULTIPLE CASINGS?0 YES S-IqO WELL CASING DIA: Z r <br /> ] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSLW UO TYPE OF CASING: 0 STEEL eVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (ml ( TREMIE TYPE TO BE USED: YAUGERS OHOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: fes -0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH - ' %1�60LTED TRAFFIC BOX or 0 STOVE PIPE <br /> ] <br /> OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?N_(if YES, list specifications here): <br /> 30MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in acco dance with San Joaquin County Ordinances,State Laws,and Rules <br /> ;nd Regulations of the San Joaquin County. Homeowner or licensed agent's signature c rtifies the following: '7 certify that in the performance of the work <br /> ,or which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's'hiring or sub- <br /> ,ontracting 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 /> NORKERS'COMPENSATION Laws of California." <br /> ,-6 LL THF—UNIT ly INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x _Title/CompanyS(� F(rlyd !,r/$T o¢�l/,¢>tiL B �nGUf2�ntl�c�,✓tAL <br /> print Name _?AAL- 1)CR-50` Date 6 ` 63-CC> <br /> SEE SITE- MAP A N1,UNIT IV WORK} PLAN �DATED 04 jurr, 2iroo <br /> DEPARTMENT USE ONLY <br /> application Accepted By v�L�LG` Dae Issued ep- 7—OCU Area S ' <br /> Grout Inspection By Date _FiriaI Inspection By Date <br /> 7 ion �a�a Date - F, 7A <br /> OMMENTS 1 CONDITIONS: /!ll�S i <br /> 4 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3s-cul S-9 / or - Cry 171V v � 3f>,SO <br /> 1/18/2000 <br />