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W& PERMIT APPLICATIONOORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHQ) _,REC <br /> `z ) <br /> .. - E. Weber, Third Floor, Stockton, CA., 95202 <br /> 'ED (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereWkaad$tVJ@@:@quin 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 CountyPublic Health Services, Environmental Health Division. <br /> ub�p�I�v1 'H�LI Cross Street Odd oak Zip Ci S' 7 Parcel#IS7 - 2GH —II <br /> WELL L ry <br /> PROPERTY Owner " r-T i A m Address f 0 13&%A 32.6 City f 1-0 '�/� ip�Phone# ;14 9 Y6 2 P707 <br /> C-57 Contractor ddress 823 'C +City r �>�ip � WLic# Z Phone# %_ 3,9A-7?ZZ, <br /> Consultant/ IlCw ? Address &4 2�7 a -2��� � ,, ,� �t i �Lic# Phone# t'i-0�7i <br /> GIS Coordinates:X�_l)f1 , Y y Q 7 9 Township / .� Range 7� Section ss <br /> WORK TO BE PERFORMED fD <br /> %NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> -gSOIL BORING# 3 0 OVER-BORE <br /> WELL#4 0,5 <br /> 5T' ft j e 3 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'eMONITORING WHOLLOW STEM DIA.OF BOREHOLE a _MULTIPLE CASINGS?0 YES ATNC� ``WELL CASING DIA: 1 e <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES d TYPE OF CASING: 0 STEEL &'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 /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH SD I g1BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <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 pertormance 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 LICANT MUST CALL 48 HRS IN ADVANCE FOR <br /> /ALL REQUIRED INSPECTIONS. <br /> Signed x Title { 7M"T 1 Date- <br /> SEE E MAP IN UNIT IV WORK PLAN DATED 3 199 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ) ft-e Date Issued 7//1//f Area 07 <br /> Grout Inspection ByDa _TFinal Inspection By Date <br /> Destruction Inspection By (�Gu D e4r{o Scr.,.�c-tee 9r-a-e(s <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED jjHEC CASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> Sp — 8'9 — 1 lo" CQ 11Ytc10/q&7G <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />