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WPI L PERMIT APPLICATIO" 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 <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 descnbed. This application is made in compliance with <br />San Joaquin County/ ED`evelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />'7/ 0n R G y S% r1 zip95Zu5 Parcet$or's <br />WELL Location /n Cn i- 5+' Cross Street 1 Cit d X r r� <br />PROPERTY Owne <br />r EZ,{ h: r �r PwG Address 21 Ou �Pmr✓ City S/1 -C x —'C/) Zip g5?iG Phone# ' ti 13 - S2cl <br />E-5L,�C&�ractS lV ,((.��; ilSi:r� ity g7oC�7 �Zip�Sza �i ftl-.1,17 Phoned Z�5- ti 7- en /SuAddress 7 GC N 1.• %SMS7 City 5711',, Lim Phone; Za7 Y(p y �cc 11 <br />GIS Coordinates: X Y Township Range Section <br />XNEW <br />WORK TO BE PERFORMED WELL/ BORING (CRT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHE '} . b /Z/(4 i 0 DESTRUCTION (choose type below) <br />OIL BORING >aL P-7 P� Q l 0 OVER -BORE <br />p*NELL ;r ow t) Ml +2. no � t Iy�4.}aJ-t,d 2%I1oo t VVo-D a PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />0 <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE- MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS YPE OF CASING: 0 S7EEEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T/1 TREMIE TYPE TO BE USED: 0 AUGERS <br />AIH 0SE Q <br />0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL 30RING 0 HAND AUGER APPROX. BORING DEPTH ,-J 0 BOL i ED i RAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? ( i` YES. list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />i nereoy certrty that I nave 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 sionature certifies the'followina: "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 taws of California." Contractor's hiring or suo- <br />contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued. l Shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of Califomia. - <br />THE APPLICANT MUST CALL 48 HRS IN ADVAN//��c)E FOR ALL REQUIRED INSPECTIONS. (� <br />Sianed x I l Title Iii 1, T l: P C C /) % Date - Zl)' 7 5 <br />SEE SITE MAP IN UNIT IV WORK PLAN. DA <br />``�� DEPARTMENT USE ONLY <br />Application Accepted By C�Cv✓L� /�a� Date Issued �j S Area <br />Grout Inspection By�� (/�y Date//e o r" ZIZIo a Final Inspection By Date <br />— <br />Destruction Inspection By �� _� �,'}y Date L .. ) "y <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID: `AC' <br />PE CODES I FEE INFO I AMOUNT REMITTED IE /CASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3�Z/ <br />C-57 CONTRACTOR SIGNATURE REQUIRED ON BACK <br />UNIT IV - 6/18/99 /sign bkpg/MI <br />