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T , j ELLPERMIT APPLICATION FZ;RM UNIT IV <br /> ,ti , <br /> SAJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> P"), 6 2000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> /IKU`v IE'1 A HEA194 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PE MIT/SEP,'✓!CES (209) 468-3449 <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 (DSL N (c(I ii-o-n"`r S�' _Cross Street Oct City kiC t7n Zip ?�,2- Parcel# <br /> PROPERTYOwner Cx Il Loos Address)I:S C S vI I UGn City 5 Zip 15;L05- Phone# y � <br /> 6`� � �z <br /> C-57 Contractor Al 14,e Address lam* AVe City S�crufrrl� ZipO/ "-� Lic# 67-�61?Phone# q/ - <br /> Consultant/Sub Contractor Address ` LA i�SU� &-6-y CityS L Lic# �' '�� Phone# `'--16/ /U� <br /> 1 cry N• <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> • OIL BORING# 'f7l4 0 OVER-BORE <br /> SWELL# n.,wl - ilnWy 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r <br /> "ONITORING >4-1;OLLOW STEM DIA. OF BOREHOLE S ` MULTIPLE CASINGS?0 YES 4-NO WELL CASING DIA:. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /l//4 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL gn+ik-2 TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:�es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH �,) bC OOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED?_ /sF (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: "I 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 performance of the work,for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR )ALL REQUIRED INSPECTIONS. <br /> Signed x 1 v AAB-" Title/Company 1D/1 Lo of /S�T,Z <br /> Print Name 1`7 rt G /Vl I I I.rn0" Date �5--IT-aU <br /> SEE SITE MAP IN UNIT- IV WORK PLAN DATED:` <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By IAI�a4A CM ` Date Issued�/�U Area <br /> Grout Inspection By I-lk�l AAA i'�a, Date 5 z- Final Inspection By �� �n u= Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3iz00 136�� f117-00od,9,495 <br /> 1/18/2000 <br />