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WEA PERMIT APPLICATION ,. ORM UNIT IV <br /> SAS} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ a sormental <br /> Health Division. <br /> NEL L Location C;°I�}Z-�l(• k�v.Mt�1 �� ��^F� ross Street r. L�Cityc�_r�e�; Zip `a�1Z Parcel# G��-' <br /> PROPERTY Owner Address Cih { zipPhonez <br /> C-57 Contractor <br /> P�C= fa- alr�r Address nSiR%haw honer <br /> 17) <br /> Consultant/Sub Contractor F 4eG ep kc,. rer.L{Address ,50 luscM�-<A Cit) +I�u Phone,: 9l� �S �� <br /> GIS Coordinates:X Y Township.--r au Range V,. Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING (CPT.GEOPROBE,HYDROPUNCH. HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING ^����Y�A�L�T�P-3 OVER-BORE <br /> 0 WALL T �`RESSURE GROUT <br /> 'Other: <br /> :CMM NTS: <br /> '"PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING .fOLLOW ST^_M DIA. OF BOR_-HOL:- MULTIPLE CASINGS?a YES�NO WELL CASING DIA: <br /> 0 EXT RACTION 0 AIR HAMMER/DR(VEN CASING THICKNESS TYPE OF CASING: 0 STEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL "��� �" TREMIE TYPE TO BE USED: AUGERS OHCS= <br /> O AIR SPARGE 0 PUSH POINT VEZ#A--GROUT SEAL PUMPED:'�KYes -&No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER �%PROX. BORING DEPTH 9-0- 't4 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? Of YES.list specifications here): <br /> COMMENTS:. tS wilt fNd�r b� Cftn,AV-,-A� 4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> 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,l shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I cerirfy that in the performance of the worts for which this permit is issued. 1 snail employ persons subject to <br /> WORKMAN'S COMPENSATION California.' <br /> T P ICAN U T CALL 48 HRS IN ADVANCE FOR <br /> ALL REQUIRED INSPECTIONS. <br /> Signed x Title C5E^'r'*" 6n2kiow- Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED . ��, E99!a <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued l Area <br /> Grout Inspection By (�,,N..t_so Date O 1 Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FACT I <br /> ACCOUNTING ONLY: I AID# <br /> i PE CODES FEE INFO I AMOUNT REMITTED CHECK/CASH I RECEIVED BY I DATE I PERMIT/SERVICE REQUEST NUMBER I INVOICI <br /> a, O( oc� ,oo ✓ �*�bb31 (Nf S R# O <br /> UNIT IV- 5/99/MI <br />