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WE". PERMIT APPLICATION `vRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520' ; h <br /> (209) 468-3449 <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 a Health Division <br /> Cross StreetVKla- S1, City C-6.w", Zippr20$ Parcel* <br /> WELL Location ►t�Z li? I�a-d�.ne `1''„' � <br /> v 4b Phone Lao >4;4-16 ST <br /> PROPERTYOwnert anr.e~n And.ti+�dted•. Address ?.a`�+X Sf0 City iPLs')-- <br /> 'N S�(`tz+ Cit Wcler, Zip`is6yl Lic#-12690 Phone# yn-41W <br /> C-57 Contractor J � Or�ll�:.� �Kt. AddresslcG S Y� <br /> nnPhone# � \%74'2�d1 <br /> Consultant/Sub Contractor Jh'C.- <br /> ssacw�y �vt.. Address tl\7 �.oae Qalvn fit.O City oh as.�o <br /> .� Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type below) <br /> NEW WELL BORING CPT,GEOPROBE, YDROPUNC AND-AUGER,OTHER•) a OVER-BORE <br /> Q SOIL BORING# 5B PRESSURE GROUT <br /> WELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE_ OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 Q <br /> 0 MONITORING `'HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASTaR WELL CASING DIA:Q �n+ <br /> - OTHER: <br /> EX'IRACTiON 10 AIF;HAMCv1ER/DRI`✓EN CASING THICKNESS T P O �4 ,1� { p t ! <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL �T E �T S (]AUGERS OHOSE <br /> p AIR SPARGE D <br /> PUSH POINT GROUT SEAL PUMPED: Yes p No (Ng MIAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING o HAND AUGER APPROX. BORING DEPTH SS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G <br /> OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> r`s <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR T PE ITS <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,1 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 /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCEFORALL REQUIRED INSPECTIONS. <br /> p Title/Company ATG A SSdc�e,�a s (vtiC <br /> Signed x aw. c4 <br /> Print Name —To�^ L—,J ��t'r""`a`^ DateyZ- ZFf 2dOo <br /> SEE SITE MAP IN UNIT lV'W0, LANE DATEQ 0Z -:lr d� <br /> _. DEPARTMENT USE ONLY �{ <br /> Application Accepted By <br /> Date Issued �' a 5 C> J Area 7 b�O <br /> Date Final Inspection By Date <br /> Grout Inspection By ! y/ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArg <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 sZa1 �t K`t — 313 C o �fa��lC� p <br /> 1/18/2000 <br /> DID C( PY( <br />