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SENT BY:9163622318-Sacra. , CA : 4-17- 0 2:25Pi11 ,RADIAN INTERNATIONAL 512 419 5099:# 3/ 4 <br /> ( ELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 804 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 209) 468-3449 y�Z d7I <br /> NOW REFUNOADLEp"_MIT EXPIRES 1 YEAR FROM DATE 1 %= <br /> Application b hereby meds to ban Joaquin County fora pe"ll to construct andlor Install the work described. This eppllcallon Is made In compliance with <br /> San Joaquin County Develc"rit Title,Chapter&1116.3 and Ito Standards of Son Joaquin County Public Health GOMA ,Environmental Health Divlabn. <br /> �/l�c��POiiT Crone 616( r 4,I Cry 7�/PCS/ --zip pL76 Paroels ; <br /> WELL Loestlon 7/Acy <br /> 7' � zip ��(o PhoneAy.0 <br /> Z-S067 <br /> 11 ROP ERTV Ownerye/AOX/jd 7?C5 � Addroes Sift-f <br /> C-aT Con6eaogylyr C�+/13TigAfBt Address cines p� uop SIAOII Phones► <br /> r r <br /> 53o-Gbz-28� <br /> °�, cdy ,�tlr4hmLy, pnnnetl 9/4'36L-5332 <br /> Consultant/Sub Controdor���t SAD%/pI� �11r�• Address <br /> 'c 2 S .g"47 Section <br /> 013 CoordillI X/V�a�lO`i$m�'v'J . yE•b.30�r+�'Z.' .Township Range —_ <br /> WORK TO BE PERFGRMED ` <br /> 0 NEW WELL f BORING(CPT, GEOPROBE,HYDROPUNCH, RANO-AUGER OTHER-) 0 DESTRUGTION(choose type below) <br /> 0 SOIL BORINGO 0 OVER-BORE <br /> — 9PRESSURE GROUT <br /> •ouwt: <br /> �(ft�cT7`d� I� oa o ei✓ e *U .sv �.�'IObrv(D U}DOKA(A _ <br /> COMMENTS:Owlgk r r <br /> T, F TA N HIS TI EC1P T N <br /> ```D��`MO��-NITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES`�i0 VVELL CASING DIA:L <br /> p 1 RACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL VC OTHER: <br /> 0 VAPOR ,IUD ROTARY DEPTH OF GROUT Spar O-I TREMIE TYPE Til USED 0 AUOERS UHOSE <br /> No NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ea O <br /> a SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH i- I 0 BOLTED TRAFFIC BOX or)$TOVE PIPE <br /> D OTHER: n OTHER CONDUCTOR CASING PROPOSEA7 (it YES,Ilst spoCdcahons here), <br /> drn ccu a/neot) A rev-," rd � C � <br /> COMMENTS: e 4/1/,/ G•Q c , <br /> s <br /> NOTE: OFFSITE BORINGS REQUI E ACCESS OR ENCROACHMENT PERMITS <br /> I hereby wNy et ave prspar¢d Ihla appice6on and that the work wig be done In eocordance with San Joaquin County Inanees,State Laws.and Rules <br /> and Regulations of Me San Joaquin County. Homeowner or licensed agem'e slgrill certifies the following: -I cerafy Msf/n the peAormanN of the worts <br /> W which this psfmH Is Issued,I shall not employ persons surh eche WORKERS COMPENSATION Laws of Celifornl.." Contractors hiring or cub <br /> cormacting signature eerdleme the tdiowlng:'f ceI that in IN perionee ce of Me eark for which this permit Is Issued.I shell ompby persons subject to <br /> WORKERS'COMPENSATION Lewes of Caft dgtiyy ry <br /> Signed x ` Title (02Oslo - /0--�-- <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> D@PAIITMENT UBE ONLY <br /> Appxcanon Accepted 13y B'Cl�^""�� nabs Issued 1 z 7 D U wN <br /> By Ode Flnel Inspection By <br /> Grout Inspection <br /> Destruction Inspectim BY Date <br /> COMMENTS/CONOITIONS: �✓ QpQI <br /> ACCOUNTINGONLY: AIDa <br /> pE CODP..r FEE INFO AMOUNT EC <br /> REMITTED CHK# RECD BY DATE PERMIT)SERVICE REQUEST a INVOICE <br /> z�©2- (�(�� (�O �l5 375 <br /> UNIT IV-6/23/99/sign bkpg/MI <br />