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W PERMIT APP <br /> SAN <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> I 304 E. Weber, Third Floor, Stockton, CA., 95202 i <br /> ^ (209) 468-3450 <br /> 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 /> Assessors <br /> San Joaquin County madDeve <br /> Joaquin <br /> Chapter 9-1115.3 and the SUndards of SanLJoaquuiin County Public Health Services, Environmental Health Division <br /> ¢,. / 7 r�/l •<G7lGl Zi �ParceW <br /> WELL Location '�dya� Cross Street.. City P <br /> r� ./ �£` �.�_ 9 AA / � ;_ City - v'1 2iphoner(�2o9 / <br /> Tj� Address i..� <br /> PROPERTY Owner�J(�- iA r `'J`� —3—`� eel .1— <br /> )(BnJIB\Y Ci Zip/-f d`'f"`'Lidt��Phon.00r � <br /> --57 Contractor �i Address l`_T <br /> Consultant!Sub Contractor <br /> MT. C'/_L r.L .� Address�✓O1Sar57G4�/ City[ Lic# Phone('Aq 7� SCG <br /> _:X_ -��Y_ <br /> .., j.. ...,, ,r...,-.:.(�pge_......._. -....,-....—Section- <br /> GIS Coordinates <br /> r� -�.__ .-- --- <br /> I WORK TO BE PERFORMED .4 <br /> 1 n,NEW WELL/BORING(CPT. GEOPROBE, HYDROPUNCH,HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING* - �'+��pr'��'-'F Q OVER-BORE <br /> ORE g 0 PRESSURE GROUT <br /> O WELL <br /> "Other: <br /> COMMENTS: <br /> -YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]'MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?OYES 0 NO WELL CASING DIA:__ <br /> AIR LOW ST /DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> EXTRACTION D TREMIE TYPE TO BE USED: 0 AUGERS OHCSE <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> O AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: O Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER APPROX-BORING DEPTH 12 D 1 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> j. SOIL BORING 0 (if YES. list specifications here/: <br /> O OTHER: . <br /> 1 CONDUCTOR CASING ROPOSEDo. <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify Ina'I nave prepared this application and that the work will be done m accordance with San Joaquin County Oroinan P s, State Laws.and Rules <br /> d Regulations of the San Joaquin County. Homeowner or licensed agent's s nature certifies the tATIOn i s of <br /> `liar in the performance o/the work <br /> for which this permif is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Cali/omia." Contractors hiring or sub- <br /> anzontracting signature certifies the following: -1 cermy that in the performance of me work for which this permit is issued, i snail employ persons subject to <br /> "dVORKMAN'SCOMPENSATION.Laws•of California. --- __ <br /> LIC NT MUST CALL 48 HRS IN ADVANCE FOR ACLREOUIRED INSPECTIONS.( Titlerr`4— �� � Date 7-171W <br /> Si9netlz SEE SI4qE <br /> MAP IN UNI IV WORK PLAN. DATE <br /> DEPARTMENT USE ONLY ' <br /> /rJ� _ff !/0i Date Issued 8- Y- 99 Area O 7 S-L <br /> ADolication Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> 1 Oest action Inspection By Date ' O ' <br /> COMMENTS/CONDITIONS: " �N'/ W ` <br /> ACX <br /> ACCOUNTING ONLY: AID* <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> C CASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> SEW 0,a-0408 <br /> UNIT IV-5/99/MI <br />