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WE� PERMIT" Fl UNIT <br /> APPLICATION FORM -Cl IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI 4,_ <br /> FIVE <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 0 6 2000 <br /> (209x468-3449 <br /> ENVIFGNMENTA',­ HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT <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 /> t� <br /> Laur wrcr(< Assessor's <br /> WELL Location—l;3? nOYSe 4 La vv- Cross Street A City -rfil 6,L4 Zipq'�27( Parcel# Z�8-30c-qZ <br /> PROPERTY Owner � Address r�Z �O <i� 1,Ct VIQ City. vIY .0 L! 2ip7rphone# ZCq"�'32— <br /> 3�- <br /> I <br /> C-57ContractorA r Address RoAA City L/In'f+4xk7 Zip C Lic# r phone#��5-s13 jg00 <br /> 2101 b�'bgtcY StYed-) 1 - <br /> Consultant/Sub Contractor(ZPGy1'�<t{V),y ��'n.KUIP^ Address_ 12t(1 CIio� City q I/.\N/f Lic# Phone#7)�"(n(P3`ylOp <br /> GIS Coordinates:X 3114 S( Y--{21.x( L_q Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT.GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) (r xDESTRUCTIOOt (choose type below) <br /> 0 SOIL BORING# VER-BORE <br /> WELL# //� 7 , /y <br /> *Other: *,PRESSURE GROUT <br /> t�ry !/ <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES ONO 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 SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G OTHER LL CONDUCTOR CASING PROPOSEDv (if YES,list specifications here): <br /> COMMENTS• (}V('r�.{rtll uVl mull T�YY VI/1 'PII G LILL GIP Irll: 1J0-t ��1n I wiI } �� f O It-'i eC}• �p <br /> J <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 /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FORALLREQUIRED INSPECTIONS. <br /> Signed x epl . //KArlt1_ Ti;te�Jt!1r'C[770/LS �4AO��P bate_(2,`z 9199 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY D�f5/Application Accepted By Date Issued o <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date Q� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES ED CHEC <br /> FEE INFO AMOUNT REMITTK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> z ov CUD DUZl6lZ. <br /> UNIT IV-6/23/99/sign bkpg/MI <br />