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WEL. PERMIT APPLICATION )RM 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 described. This application is made in compliance with <br />San Joaquin County Development Tale, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />'NELL Location l� �� � � ^•tiu� Cross Street t-�cArrnu►rl�v�� City � oaf _ Zipcl Z Z Parcel# CSR7-,OgO 3-1 <br />PROPERTY Owner Gm- �ft]rlQUYIu�'t1 Address 555 (�+cvot� E—A, City 21L a^ Zip°1521S Phonez <br />C-57 Contractor �(� i� ��, Address38 �ac_r1nc��� _Cit ��jt� ZiP�`' Lic4LSSQS4a Phone# <br />Consultant! Sub Contractor C=5p;fAA (C.Address Sri L-tus9M', CAY(k,,N ta�JU? Lrc-- Phonez 6IQ 773-P&;1( <br />5ufEk/1 <br />GIS Coordinates: X , Y Township 1i.b1 Range-�Is: Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (chooseR-BORE below\ <br />>C -SOIL BORING # 'R& • , Glis � .1sA-� <br />0 WELL z rVRESSURE GROUT <br />-Other: <br />COMMENTS: <br />�r= yrVVCLL ,,../v,.r'•• ---- - <br />O MONITORING 1WOLLOW SiCM DIA. OF BOREHOLE `6 MULTIPLE CASINGS? Q YES >rNO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALL � �, Sl �� TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT ��ROtJT SEAL PUMPED: 'es ZNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER APPROX. BORING DEPTHg0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br />nereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Orainances, State Laws, and Rwes <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permif is issued, I shall not employ persons subject. to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br />c.ontracting signature certifies the followin : 'I certry that in the performance of the work for which this permit is issued, I snail employ persons subject to <br />WORKMAN'S COMPENSATION La of lifomia.' <br />T A L,l AN ST CALL 48 NRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x / Title �OEr iGU�o(s b Datezzz <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATEDr`�-���x- t�t� <br />DEPARTMENT USE ONLY AApplication Accepted By. <br />Date Issued / O Area � P <br />Grout inspection By I ��AA-Irl_Date l0 ? Final Inspection By Date <br />Destruction Inspection By Date r <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE IN AMOUNT REMITTED CHECK»/CASH RECEIVED BLNDATE I PERMIT! VICE REQU T NUMBER INVOICE <br />ado i oc> I X 03 I 0 o <br />UNIT IV - 5/99 /MI <br />