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WELIlwoJERMIT APPLICATION FSM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MMNEID <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") NOV 12 2002 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED PERMTSERVICES <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 nd the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> NELL Location A"-4y4Lo Street City ZipQ�_Parcel#. ' -`OG••/�f <br /> tIROPERTY Owner c. S .c Address 1/ ity Zip s Phone# W sya.3 <br /> C-57 Contractor I;/tf-GJ Address &;_Y/r; _Ci C�_Zip95-W Lic#2LQg Phone#9a-777 Y/Ott <br /> -onsultant I Sub Contractor Addre s � �7 City��Lic#U 173 f Ahane#2M <br /> 31S Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED <br /> ]NEW WELL I BORING(CPT.GEOPROBE, HYDROPUNCH,MAN AUGER,OTHERry _ a DESTRUCTION(choose type below) <br /> ASOIL BORING#^ S �ac� s OVER-BORE <br /> a WELL# PRESSURE GROUT <br /> 'Other: <br /> 'OMMENTS: _ <br /> rYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING a HOLLOW STEM DIA.OF BOREHOLE /--�L N MULTIPLE CASINGS?a YES [I NO WELL CASING DIA: <br /> J EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> ]VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS QHOSE <br /> J AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING a HAND AUGER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ]OTHER: 6+:0 1 k e CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <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: '7 certify that In the performance of the work <br /> for which this permit Is Issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomla." Contractor's hiring or sub- <br /> zontracting 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 /> WORKMAN'S COMPENSATION Laws of Califomis." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed0� <br /> x Title Date_,�Q—Z3 —[TIS <br /> SEE SITE MA IN UNIT IV WORK PLAN. DATED -- + _t 2oa <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> /. <br /> Grout Inspection By �� nn.. _ Date Final Inspection By t)at <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE I RMITi REQ ST UMBER INVOICE <br /> 3Sa $ S-1.ao S�3 It Z <br /> UNIT iV-6/18/99/sign bkpg/MI <br />