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WEL PERMIT APPLICATION .RM <br /> <br />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) 468-3449 <br />RECEIVED <br />NOV 1 6 1999 <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />, Assessor's <br />WELL Location 56/ iiffnadattri De Cross StreeePfeectidd • City Zip 47,533 1 Parcel# <br />PROPERTY OwnerLottlytuk 14v41' rt S Address 5( 1Al4Lue,06( CityYtAAU,A, Zip9 5337 Phone# <br />C-57 ContractorOJ 1u'.ig Address W.) Sib' S'k— City1Sle4tn—t Zipqq41( Lic#72C/404 Phone#016111 -1•41 LOO <br />Consultant / Sub Contractor 67rtiviall 2A-0 Address nIt-k IMaik.1 SA- CityFscay, Lic# — Phone# g38--Cillsi" <br />U\1 <br />GIS Coordinates: X Y , Township 2 3 Range -1. E. Section t.9. N. <br />WORK TO BE PERFORMED <br /> u\i <br />clf-I:10/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />a SOIL BORING # <br />'"AIVELL # vj I, wiwz, 4 1vt.t4 1-1 <br />COMMENTS: <br />*Other: <br />0 DESTRUCTION (choose type below) <br />a OVER-BORE <br />0 PRESSURE GROUT <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING XHOLLOW STEM <br /> <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR OMUDROTARY <br /> <br />AIR SPARGE a PUSH POINT <br /> <br />a SOIL BORING a HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />C.... <br />DEPTH OF GROUT SEAL el- TREMIE TYPE TO BE USED: 0 AUGERS ['HOSE <br />GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') c <br />APPROX. BORING DEPTH <br />s, <br />fct )(BOLTED TRAFFIC BOX or a STOVE PIPE fc <br />CONDUCTOR CASING PROPOS JO ( if YES, list specifications here): <br />L.> <br />-N \ <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES *0 WELL CASING DIA: .4 <br />I <br /> f• <br />CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC a OTHER: <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 k <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ 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 performajce of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSAT • Laws of California." <br />TIE A T MUST CALL ORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title '.4t2/9C gerk'SIS Date ///2 7/06 <br /> <br />SEE ITE MAP UNIT IV WORK PLAN DATED: (55/161z000 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />tAt..4.1.Arch <br />U .--•,/k/vtrov\ <br /> <br />DEPARTMENT USE ONLY <br />Date Issued 11-1 100 <br />Date ", I C4 Final Inspection By <br />Date <br /> <br />Area <br />Date <br /> <br />COMMENTS / CONDITIONS: <br /> <br />ACCOUNTING ONLY: AID# <br />i <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - - ---; - - EQUEST # INVOICE <br />olos---z_ ., ./ <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORK1MPENSATION <br />UNIT IV - 6/23/99 /sign bkpg/MI