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WE&i2 PERMIT APPLICATION UNIT IV <br /> SAI4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Fioor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 96-1115.3 and the Stancards of San Joaquin County Public Health Services. Environ <br /> ess al ealth Division. <br /> 'NELL Location-? 11 It -4) 61�' �'2^ ��Cross Street CitylZ_ParceW 69-7:,2410-33 <br /> PROPERTY Owner _Address City5jAe �EDr' ZipA5ZtS Phone# 11,,3(- <br /> �•37 Con[raaork_kn��s�toh AddresscO� �ie' City�iarrjl� _ZiP45 Lic$o�c,555�_Phone �4fb�h13rf � J <br /> Consultant!Sub Contractor {*:Address 'f Cityr�itV,Il�Liu�' Phone;. `lIG �T�d.:.Cx� <br /> Su�L•�1! <br /> GIS Coordinates:X <br /> Y Township -T, Range Section 1 c� <br /> INORK TO BE PERFORMED <br /> NEW WELL I BORING (CPT, GEOPROBE.HYOROPUNCH,HAND-AUGER.OTHER-) O DESTRUCTION(choose type below) <br /> ><SOIL BORING R la>L4, ao'a�r14—� a OVER-BORE <br /> O WELL tWPRESSURE GROUT <br /> 'Other: <br /> -::;;MMENTS: <br /> ^vpc OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFECATIONS <br /> O MONITORING AlatOLLOW S—'-M DIA_ OF 30RE,'-IOL- $ ' MULTIPLE CASINGS? 13 YES)KNO WELL CASING OIA: <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STE EL O PVC O OTHER: <br /> O VAPOR O MUD ROTARY OFPTH OF GROUT SEAQ "6 El } - 7REMIE TYPE TO BE USE: C3 AUGERS OHOSE <br /> O AIR SPARGE O PUSH-..POINT ROUT SEAL PUMPED: Yes --JJ�No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER APPROX. BORING DEPTH .6-5' _O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> O OTHER: CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> COMMENTS: c �� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i hereby certify that I have prepared this application and that the wont wilt be done in accordance with San Joaquin County Ordinances, State Laws. and Ruies <br /> anc Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "l certify that in the performance of the work <br /> for which this permit is issued.I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> :;ontracting signature certifies the followin : 't certify that in the performance of the work for which this permit is issued. i snail employ persons subject to <br /> tNORKMAMSCOMPENSATIONLa Of lifcmia.' <br /> T71 A AN ST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> Title C7 to Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 1 <br /> DEPARTMENT USE ONLY <br /> AppiiCBtion Accepted ey Date Issued O ea <br /> Grout Inspection By Date }p t9 Cl Final Inspection By to% i:v —. <br /> l <br /> Destruction Inspection By <br /> Date I <br /> COMMENTS I CONDITIONS: <br /> li <br /> co <br /> ACCOUNTING ONLY: I AID+'t <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOIC' <br /> 12.cto <br /> UNIT iv- 5/99/MI <br />