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V1trL-:� PERMIT APPLICATION i-_,R6', UNIT IV <br /> SANJOAQUIN COUNTY PUBLIC HEALTH ' IC 0g $ <br /> ENVIRONMENTAL HEALTH DIVISION ("PMS- iTX99 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95102 `/Iv; '9 <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> WELL Location 6 3 q W'S T C [o\/ 5)V„ r Cross Street �I a 1`✓'i i 0V\ City 5,)o Zip Parcel# y <br /> PROPERTY Owner P55 Como rAc l te; i Address 6S y L`✓. C la It 5 L City Zp Phone# q 030 <br /> C-57ContraaorJlclVcur 'c� (�odFHvi�aN11Zr tss ` in r, IV- in/;Ile,,, V/4y City Stot141 Zipg4;e LiG650;137 Phone# �6T'IOC� <br /> Consultant I Sub Contraaor 00(4, 11 pr,I I"!v Address f.o'H0 I City(k,O,-ku [c rdfLiG 6 7 J-617 Phone#j 3E -`166y <br /> .;IS Coordinates:X YTownship Range Section <br /> WORK TO BE PERFORMED <br /> ^21 NEW WELL/BORING (CPT. GEOPROBE,HYDROPUNCH. HAND-AUGER.OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# p OVER-BORE <br /> 0 WELL R 0 PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> T"PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING g HOLLOW STEM DIA. OF BOREHOL=_� —MULTIPLE CASINGS? 0 YES ® NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT- 1� T REMIE TYPE TO BE USED: 0 AUGERS ®HC _ <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH �( 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? KI ( if YES. list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> nereov certify that I have prepared this application ano that the wont will be Cone in ac=rcance with San Joaquin County Oranances, State Laws. and Ruies <br /> and Regulabons of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: -1 certify that in the performance of the work <br /> for which this permit is issued.I shall not employ persons subject to WORKMAN'S COMPENSA777ON Laws of Califomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which Lhis permit is issued. I shall employ persons subject to <br /> h'ORKMAN'S COMPENSATION Laws of California.' <br /> 11 At <br /> APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x/kwi,, '!t� �� �M T itle r ti �c j c[c�i,5 I Date <br /> SEE SITE MAP IN UNIT IqV/WORK PLAN. DATED <br /> /I �J� � DEPARTMENT USE ONLY / C� �o <br /> Application Accepted By / `' . Date Issued i ( / Area J / <br /> Grout Inspection By Date I Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: / ' B Y , - C <br /> FAC# <br /> ACCOUNTING ONLY: I AID# <br /> I PE CODES I FEE INFO AMOUNT REMITTED I CHECK:JCASH I RECEIVED Y DATE I PERMITISERVICE REQUEST NUMBERINVOICc <br /> t <br /> UNIT IV-5/99/MI <br />