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2-10-2000 1 1 :24AM FROM -� .- p. } <br /> j. <br /> F <br /> �,L PERMIT APPLICATION FORM j,UN1T IV <br /> WE . <br /> A Oji �`V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERI ,. <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ` y <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED plication is made in compliance with <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap <br /> ;an Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division.' <br /> ,✓� { I- (,J N), n _. t Lr' Iz i Cross Street City I c<� Zip Parcel# <br /> �LLLocation�,, 11--1 _-�--�.�- cicy� �Z,,,r,,,iQ`•� <br /> Phonei* <br /> PROPERTY Owner.� JiGc i n LL"LV Z Address G C ^.+� ZC City_ Zip <br /> J (� ddress Z Z�t'I Pc��J 1t/2. City�f. {�iLl"wLpGl�(�L'�Lic# csb`� Phone# <br /> C-57 Contractor Y�.- Fes,S r. r P <br /> •,` r'C`vu v'c. 141c'-•. Lic+ Phoneis�ir c -�/C.�ci <br /> Consultant/Sub Contractor :t. w '��JAddress- <br /> GIs Coordinates:X <br /> Y Township_ Range Section <br /> WORK TO BE PERFORMED <br /> �f=STRUCTION(choose type below) <br /> G NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER*) <br /> OIL BORING# Q OVER-BORE <br /> Q S Z tr2Us ]PRESSURE GR UT <br /> (I WELL# W <br /> *Other: <br /> coMM>=Nrs: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES B NO WELL CASING DIA: <br /> EXTRACTION Q AIR HAM MERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL Q PVC O OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U AIR SPARGE <br /> U BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> a SOIL BORING a HAND AUGER APPROX.BORING DEPTH---- _ <br /> 0 OTHER:�_U OTHER CONDUCTOR CASING PROPOSED?-(if YES,list specifications here): <br /> COMMENTS= <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHME T 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 tha following: "I Certify that in the performance orthe work <br /> for which this permit is issued,t shall net employ persons subject to WORKERS'COMPENSA770N taws of Califomia_" Contractors hiring or sub- <br /> contracting signature ceRifies the following: 71 certify that in the performance of the work for which this pemlft is issued.I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cafifornia,' <br /> CALL'Ttit'UMTIV INSPECTOR 48 WORKING HRS INADV,ar►XCEi-.FIOR.�A}�LI.REQUIRED INSPECTIONS. <br /> Signed x- Titlelcompany V }r <br /> Print Name <br /> Date y •_,.,,.. ,, - <br /> s _ _ „.. :.. _-• ice :_ <br /> ' I�::a'���Gi,��: "."J..•Y;M1";.�:1f:�'JRCA'SP �r.�A�FEE)•"C` — <br /> „y,�Jypss.fiurti.r+ued�r <br /> DEPARTMENT USE ONLY <br /> U t„� Date Issued b + Area <br /> Application Accepted By G <br /> Grout Inspection By <br /> ��� _oate Z O Fina[Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ET <br /> ONLY: AID# <br /> EE INFO AMOUNT REMITTED CHECK# RECT BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br />