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WELrPERMIT <br /> APPLICATION MRM UNIT IV <br /> SAN JOAQUIN COUNTY WJBLX HEALTH SERVICES'1`r�.:�,��'i,_ <br /> ENVIRONMENTAL HEALTH DIVISION ( PHS-EHD ) HEAL)11 <br /> 304 E. Weber, Third Floor, Stockton, CA.,195202 � ��F <br /> (209) 468-3450 03 Nov-7 4. <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED 0� <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 oomplianc' 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 /> WELL Location ross Street �r� Ci 0 �n Assessors <br /> -city Z'ip -1��i'3 G/ Paroei# <br /> PROPERTY Owner Address Cily ZipGttG�Phane# 5 Ei "5 <br /> C-57 Contractor <br /> Address: City, Zip 7SLic# hone# p <br /> Consultant/Sub Contractor o r Address r2- City�S'_t.0 Phone# L53 S'/ y <br /> GIS Coordinates:X YW_ „!Township Range Section <br /> WORK TO BE PERFORMED <br /> NEVY WELL l BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHERS D <br /> Q D RUCTION{choose type below) <br /> Q SOIL BORING# Q OVER-BORE <br /> *Other �NVELL# Q PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> *ONITORING L10LLOW STEM DIA.OF BOREHOLE !�L MULTIPLE CASINGS <br /> ?�`YES Q NO WELL CASING DIA: .Z <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS !�Lg TYPE OF CASING: Q STEEL p;PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL = TREMIE TYPE TO BE USED: <br /> Q AUGERS .aIiOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED:A Yes Q No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER APPROX.BORING DEPTH Cr, .IrBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: CONDUCTOR CASING PROPOSED? G ('if YES,list s <br /> p�cifications bora): <br /> a t <br /> COMMENTS: I <br /> L' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR RNCROACHMENT 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 th' San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I cerlfl�r that in the performance of the work <br /> for which this perm Is Issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signatu certifies the following: 7 certify that in the performance of the work for whkh this permit is issued,I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California." <br /> TH APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> / <br /> Signed x _ Title L.�� / Date(___- <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED2 .2�L``3 <br /> �. i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By A3Date Issued 1,4731 Area - <br /> Grout Inspection By L4Data�_ Z Z Final Inspection By 0_4 ri u e_� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: eq+— * '6,1 4%z h,yyw"r <br /> ACCOUNTING ONLY: AlD# <br /> FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKMICAS14 RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER .INVOICE <br /> 31 �gr�oo s3r,60 os <br /> UNIT IV-6/18/99/sign bkpg/MI <br /> (Capoy <br />