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WEIPPERMIT APPLICATION ARM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) { two 4ENT <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 REnE i <br /> (209) 468-3449 im 10 z <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 applicatio ��KE�,,with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Sew. 02 1 Bhk91f'fllAn. <br /> WELL Locationd,2131 d he�I PV t Cross <br /> 9Street <br /> �,y, a City Zip c/,/� parcel# is <br /> PROPERTY Owner JACK 6VYd -n Addresso�3a �'d�flrl�,Yi Jet City /�'� I ZipVCCl� -y—Phone# 500-5-413 <br /> C-57 Contractor -�'21 M WI&,Address_a31PS W1 UfirA-4.City -Ap-Cpl• Lic# 5QWPhone# q j:17G,- <br /> v 1�L �aA <br /> Consultant/Sub Contractor, Address QIP 6M o ity4PO Lie# Phone# <br /> U , <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# O PRESSURE GROUT <br /> "Other: 4' l-FV,- JZ tiN PJ✓'r F Y'i',pV14L- <br /> COMMENTS: 1A,ro" ?I.11Ki T'D A S w iff`C10 Rte IiJyattV&'I P 1� 'M <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 O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC 0 OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> O AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING O HAND AUGER APPROX. BORING DEPTH n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 1AICOMMENTS: tiorNr,$1C. Qeu- IS r N.>+1 mz z` TC.6 - sw - IS f.-bw4a i 7o f3' Ae5,TLJg 5 <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 PPPLICANT MUST CALL 48 WORKING HRS IN ADVANCE 'FOR ALL REQUIRED INSPECTIONS. <br /> Signed '� Title nie-0 ,�'1(ms IUGK, Date 1"` �0- 7�� <br /> SEE SITE AP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �/iM1-rv9 Date Issued Area <br /> Grout Inspection By Date Final Inspection B Date <br /> Destruction Inspection By Date. <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> P IE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �lD II(7v 991 I l� Ino. <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICE E&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />