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WEL,tePERMIT APPLICATION P1 RM UNIT IV <br /> iV <br /> \�\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �C\ ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304iE. 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`Or a permit to construct andlnr 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, Environmental Health Division <br /> g ow lu C- <br /> V4!LNI_Location 3 LVab f� Cross Street � City Assessor'siParcel#G _z � Z _117 ­)- <br /> 7 -d 3 J <br /> PROPERTY,Owner 19'IGrL/y,??3f' / <br /> Address 6 3u Cit Zip hone#-?,::�J 31i2- F7d7 <br /> C-57 Contractor y;!t rI✓` Address C'-`j <br /> Cityl�7 .t Zip Lic# Phone#f/L ?�7 fr/d� <br /> Consultant/9at� Address 0 D g <br /> �� City ��L�_Phone# s�7 Z�- <br /> GIS Coordinates:X_jE 7�.-.�U-U Y S`3 P Tr t5 b Township 2 N Range � <br /> 9 �. 4 Section �d <br /> YvORK TG B't PERFORMED - _ <br /> AP46INWErL/BORING(CPT, GEOPROBE, HYDRO PUNCH. HAND-AUGER, OTHER-) " <br /> SOIL BORING# Q DESTRUCTION(choose type below) <br /> WELL# Q OVER-BORE <br /> 'Other: <br /> COMMENTS: Q PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT1pNS <br /> Q MONITORING gHOLLOW STEM DIA. OF BOREHOLE <br /> Q EXTRACTION CASING <br /> CASiNGS�(]YESNO WELL CASING CIA <br /> AIR HAMMERlDRIVEN CASG THICKNESS�_�TYPE OF CASING. Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> (]AIR SPARGE Q PUSH POINT TREMIE TYPE TO BE USED: Q AUGERS QHOSE <br /> GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH <br /> Q OTHER: Q OTHER Q BOLTwD TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> ( if YES, list specifications here): <br /> COMMENTS: <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: 'Y certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the peearmance of the .vork for which the permit is issued. 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T PL NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />� Signed x /�� ^ <br /> Title (-2l,�y 4116 <br /> Date <br /> SEE SI E MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY q <br /> Application Accepted By Date Issued l � � � � C{ <br /> Grout Inspection By 4 t — Area <br /> Destruction Inspection By ate O Final Inspection By Date <br /> Date ---�- <br /> COMMENTS CONDITIONS: L'Q rlVpr� f-O yk.E Q m <br /> m b o rr 'e- CLu er g o e <br /> r� Ir•� <br /> ACCOUNTING ONLY: AID# FAC# <br /> i PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITiSERVEST NUMBER INVOICE <br /> 3So I g� B� 5 � ICE REQUEST <br /> D 0 -7 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />