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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.Weber,Third Floor,STOCKTON,CA 95202 MPDIY <br /> (209)466-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM GATE!SSUED <br /> y for a permit to construe!and/or install the wort;descrbed. -his application is made in Compliance with <br /> Acolication is hereby made b San Joaquin Count <br /> :an Joaquin County Development T ttle, Chapter 9-1' 5 3 and the Standards of San Joaquin <br /> County Public Health Sa vices, Environmental Health Division. <br /> �(�2:1Cross Street (, 'hC C'ty -DZ, — Parcel# <br /> Site/Jab Address ' 1 i2 Z �%� <br /> 7 L 7_Ai L�` Air: 5 Li:'• Address AE - —(E r' :S y,S,r. Phone# <br /> `wner's Nane Ur-�) ?rCr+ <br /> D fJ�• LiG3 Phone# <br /> 'cntractor J5--, Address X77 IAC 1�i <br /> Address — / <br /> � V �� S i(A Phone# G1as Zi a SGC <br /> {� <br /> Wntracior rte <br /> %:CRK TO BE PERFORMED <br /> ESTRUCTIO (chooseype Below) <br /> ] 'i � <br /> TvV WELL/BORING! CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER OTHER') VER-BORE <br /> Q SOIL BORING# PRESSURE GROUT <br /> I]WELL A L <br /> -Crher. <br /> �CMMENTS: <br /> ype ap yyE�L CONSTRUCTION TYPE CONST RUC-ION SPECIFICATIONS WELL CASING GIA: <br /> DIA. OF BOREHOLE UUL7PF`O ASINGQ STEELN <br /> SINGS? <br /> �YES 0 <br /> t]MCNITORING 0 HOLLOW STENT �PVC Q OTHER: <br /> EXTRACTION Q AIR HAMMERJnRIVEN CASING THICKNESS TrZEMIE TYPE TO BE USED: L7 AUGERS OHOSE <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL <br /> 7 :IR SPARGE Q P'JSH POINT GROUT SEAL PUNIPSC: 0 yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> APPROX.BORING DEPTH aLCCKING CHESTER BOX or Q STOVE PIPE <br /> 0 SOIL BCR.ING 0 HAND AUGER CONDUCTOR CASING PROPOSED. ',if YES.Ilst soecttfcatlons here): <br /> OTHER. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereoy certify that 1 have prepared this application and that the work wiil be done in accordance with San-loaquin Caunty Orcinar.ces,State Laws, and Ru!es <br /> and Regulations of the San Jcaquin County. Home owner or licensed agent's signature Certifies the following: "(carni`t that in the;7— o rance of the worn for <br /> vhrch this permit is issued, t shall ret employ psrsons subject to WORKMAN'S COMPEVSA7ON Latus of California.' Contractor's hiring or sub:-contractrg <br /> thi <br /> signature certifies the f01l0w;ng: -,rer•JfY tnat to the performance of the work for:vnicn s Nemif is issued,f snarl errploy;.ersons subject.o WC•4K,Y1AN S <br /> COMPEN TION Laws of Califomia." THE•APPLICANT MUST CALL 48 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)468-3460. <br /> �— Title �gi yL& r-1 �tQk-LTeYZ Date <br /> Signed x ��y C l 1rCr <br /> DEPARTMENT USE ONLY /I tr v��(1 <br /> Date Issued Area I <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction!rspection By Date 6 <br /> COMMENTS: rj0ao <br /> 0 � <br /> FAC# I' <br /> I' ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO I AMOUNT REM, ITTED I SHECKNICASH RECEIVED BY DATE PERMITtSERVICE REQUEST NUMBER I INVOICE <br /> UNIT IV/10-98/MI <br />