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WEP PERMIT APPLICATION %RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> l 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 incompliance with <br /> San Joaquin County Devel/oprr/n�e,nt Title,Chapter 9-5115.3 and the Standards of San Joaquin County Public Health Services,Environnu6bl Health Division_ <br /> WELL Location,141 !S f7L� Cross Street �i��L�•�.>}city Zip —PAssesgw's <br /> PROPERTY Owner /Yri Address. 152-1 Al P,4 Sj�- City i Phone# <br /> C-57 Contraaor IOO C t' Address202—, (�City ip ,s J , hone# AaZ <br /> Consultant I Sub Contractor Address City ,Llc# Phone# <br /> GIS Coordinates:K,.Y Township Range„ Section <br /> WORK TO HE PERFORWE-D <br /> 0 NEW WELL 1 BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') p DESTRUCTION(choose type below) <br /> 9 SOIL BORING# 0 OVER-BORE <br /> 'Other. D WELL# <br /> 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 I f _MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMiE TYPE TO BE USED: j]AUGERS OHOSE� <br /> Q AIR SPARGE ,�isUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30+—�_ <br /> ra.0I!!5lL BORING 0 HAND AUGER APPROX. BORING VEPTH__3,--I _0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> J OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> — - <br /> � C <br /> NOTE: OFFSITE ORING6 REQUIRE AC SS OR ENCROACHME P RMITS <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> Ind Regulations of the San Joaquin County. Homeowner cc licensed agent's signature certifies the following: "i certify that in the performance of the work <br /> or which this permit is issued,f shall not employ persons subject to WORKERS'COMPENSATION Laws of Cailfomia." Contractor's hiring or sub- <br /> :Ontractiag signature certifies the following:'l cer*that in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> NORHERS'COMPENSA TION Laws of California.' <br /> /T&E APPLICAIINT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> iigned x (/t/G�`��* �—. Titre C-7r-zi p-To'�` Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> %Ppl'rout Inspection <br /> Accepted ay��i`�dr� - Date Issued Arae 0 73 <br /> ;rout inspection By� Date Final Inspection By Date <br /> ]estruction Inspection ByDate ///3/JPO d' �/ a P S I� t D <br /> ',OMMENTS i CONDITIONS: <br /> ACCOUNTING <br /> -ONLY: AID# <br /> FAra <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> 'MIT IV-6/23/99/sign bkpg/MI <br />