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WA PERMIT APPLICATION . ,ORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> S�15 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209r 468-3449 30 <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/Qr 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 Health Division. <br /> WELL Location �) ! W�� �1Crass Street ` I� Assessor's <br /> �µI E::w1 City Y nul;s Zip`I�38S Parcel# <br /> PROPERTY Owne6w'z4)e.rn 1cuYn Serve- ii Address 0O IIS City rresw Zi 93715 <br /> e/o M. elle _ I}L P Phone# <br /> C-57 Contractor E re12 Dnll,ew; 'e Iii 1v Address iStJ Mo We CityA'lar4inez Zip`14553 Lic#4 5-151 Phone <br /> #(qZS) 3r3 53�w <br /> Consultant/Sub Contractor Cori-wfarFs Address 2W1 Wck4--rS4 12' �(-Ror City0a,0gnJ Lic# Phone#(5���3 41cti <br /> GIS Coordinates: X ,Y Township Range 9 Section <br /> WORK TO BE PERFORMED <br /> [ANEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH. HAND-AUGER, OTHER-) O DESTRUCTION(choose type below) <br /> J$SOIL BORING# y <br /> WELL# 0 OVER-BORE <br /> 'Other: O PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING g HOLLOW STEM DIA. OF BOREHOLE- <br /> MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL O PVC O 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 0 BOLTED 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 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'C MPENSATION Laws of California." <br /> H APPLICANT ST AL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title_ <br /> SEE SITE M , IN UNIT IV WORK PLAN DATED <br /> / n DEPARTMENT USE ONLY <br /> Application Accepted By `q <br /> Date Issued (z z- / 5j Area Ll7i/L G f Si <br /> Grout Inspection By T` <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC #/ ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> UNIT IV 6/23/ <br /> C - 99/sign bkpg/MIO , C 'IVC <br /> Z 'd <br />