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05/10/00 WED 17:27 FAX 510 6F- '1350 GEOMATRIX OAKLANDQ'1a 6'1 RA L <br /> OWELL, PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 5 — `- <br /> (209Y 468-3449 eor.1 t:01,- <br /> OD /(S <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/tv install the work described. This application is made in compliance with <br /> Sart Joaquin County Development Title,Chapter 9-11'15.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> 5. Stiovtedtn- an QWo�ellield Assessors <br /> WELL Location W. L 1�3 S}ree-� Trac Lt4 Cross Street s City r�� Zip f53,fr Parcel# <br /> PROPERTY Owner City 0,C -7•ra.e- Address S"Z o Tog. c`I Q lud. City Tr a C: zip '?L Phone#�2d`1)f131 94 Lo <br /> C-57 Contractor O/acisio�l Sw�.�fir,�rYne_Address IW S" SGL` Sffc-4- City gickmgeA Zip?Vf0q Lir*A 63 , phone# 7I 7f <br /> Consultant/Sub-Goatsactor Ge0m.1+Yi 6ASUlfa.rfS _Address 2101 Wpb � SF_ City � Lic# Pham#�x/o}663-yloo <br /> fa �riaas/ <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO HE PERFORMED <br /> BORING CPT,GEOPROSE,HY ROPUNCH,HAN -AUGER,OTHER-) - D:rc� FPS6 (I DESTRUCTION(choose type below) <br /> 0 SOIL 50R{NG Gfn --- bo.i e,I e) bo- bac k piL1 Pe! Ori/bt 0 OVER-BORE <br /> a WELL# Co PRESSURE GROUT <br /> 'Othe40-0-14 9io. f W"t" a Tiri►s:c i e. <br /> r. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 1]HOLLOW STEM DIA,OF BOREHOLE 3 ' MULTIPLE CASINGS?Q YES 9NO WELL CASING DIA, <br /> — <br /> 0 EXTRACTION C AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: Q STEEL Q PVC Q OTHER; <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: O AUGERS CHOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS.301) <br /> $SOIL BORING Q HAND AUGER APPROX.BORING DEPTH 2S Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: Q OTHER CONDUCTOR CASING PROPOSED? (If YES.list specifications here): <br /> COMMENTS: PN,-,-6F P- r rriL) ��i�tf�ro,.;r. Ka:l 25J iA5/aN ler"p. "d,4 FvC Ca5,1" -, <br /> .k�,l+-� �r ro,.n.d rrg.�� �d r neo tri b e. ba.cac�o I l+� W�y1n- GeMe�,j- y�o✓f t.�r {-6, ?i r,vi.i,e IO i,oma„e� <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 tho work <br /> for which this permit is Issuad,L shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hiring or Sub- <br /> contracting signature Certifies the following: 7 certify that In the performance of the work for which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws Of Califomia." <br /> THE APPLICANT MUST CALL 48 HRS I ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x o-i SR�!W ✓ -� Tltle�� Date <br /> SEE SITE MAP UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY c <br /> Application Accepted By <br /> Date issued <br /> Grout Inspection By Date Final Inspection By •OU <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AIDS <br /> PE CODES FEE INFO AMOUNT REMITTI_D CHECK#/CASH RECEIVED BY DATE PERMIT)SERVICE REQUEST NvmSER INVOICE= <br /> 2.q o I �.. -1 I _ Oct Z`2- 27 <br /> - - <br /> UNIT IV-6/23/99/sign bkpg/MI <br />