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W6w—,L PERMIT APPLICATIOIWORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location ISO W. L,,..s A L,e- Cross Street/V. Ma;v, City/"Ac,✓l"ccs Zip Ss Parcel#JJV7 d? <br /> PROPERTY Owner M:ke Q:o r, Address I LI k& E, Loud c ALPe. City Z(4 n4e- Zip y.S- (o Phone#,,2011-Pa3-3?c/S' <br /> C-57 ContractorG r e-11* 0r:1Irv%S Address 9'r& /10 ore Acca( City/I. r Zip? r L3Lie#''/FS//JPhone#9�5-313S�rOd <br /> l_ <br /> Consultant/Sub Contractors m Lr•r"o, E,yrro.,,,wn/A+Adress1!5(U 61- k, S+,Sv, CitYCha IAC la A Lic# Phone#,$'10-y.20-0740 <br /> GIS Coordinates:X 'y Township Range Section <br /> _ WOR <br /> K TO BE PERFORMED <br /> R/NEW WELL/4jORING(CPT,�jQ�PRQBHYDROPUNCH,HAND-AUGER,OTHER*) 1]DESTRUCTION(choose type below) <br /> SOIL BORING#S 38-3, SB- JQ'S, SA—Co []OVER-BORE <br /> []WELL# PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?[]YES []NO WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS /l/A TYPE OF CASING: []STEEL 0 PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL ,Oft°-y''t TREMIE TYPE TO BE USED: D AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: []Yesz/[]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING []HAND AUGER APPROX.BORING DEPTH 7 s []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> []OTHER: ff-6THERGeprAe- _ CONDUCTOR CASING PROPOSED? IVA (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,State Laws,and Rules <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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's 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 /> WORKERS'COMPEivSATION Laws of California." <br /> .CALL THE UNIT'IVNSPE TOR 48 WORKING HRS IN,ADVANCE FOR,ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company e <br /> Genlorijl-,, CQ <br /> Print Name J)ot crc Date <br /> AA DEPARTMENT USE ONLY <br /> Application Accepted By q <br /> D _ Date Issued ��' ��` (. Area 1 <br /> Grout Inspection By °��- lir' -+�tl Date �� 4- Final Inspection By `�'. "t Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sg# <br /> 1/18/2000 <br />