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WE_... PERMIT APPLICATIONPORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209r 468-3449 <br /> NON-REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/pr 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_ S 07 S. (,j..kt QA., , I Assessor's <br /> Cross Street Welk 0"(A City 4Zii-nGt16 Zip`153$ Parcel# <br /> PROPERTY Ownerk4e /Vc:man tfI iL. -/c JS.&':nCAddress (160; (-I`Ameit- ))i-, City04k RizcL Zip GO5Zi Phone# <br /> C-57 Contractor-(,-Ee4q DOI, yt144" 1-m Address`150 Howe Kce� City A 'L)eL Zip o <br /> `553 Lie#48S-I6 Phane#(9J_5�3/3-5�, <br /> Consultant/Sub Contractor L2 YYLA C­150 6n{S Address 2J('! 14'204?i IZrh -City(JG U(01 1 Lic# ' Phone# <br /> GIS Coordinates:X Y Township Range 9 Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/,BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER')SOIL 0 DESTRUCTION (choose type below) <br /> ]WELL#ORING# 1 0 OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER- <br /> 0 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: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 5(SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 SOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER: 0 OTHER CONDUCTOR CASING PROPOSED <br /> (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, StateLaws,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,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: /certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS' OMPENSATION Laws of California." <br /> E APPLICAN 7UMU ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title - Date /611IZ119 <br /> s <br /> SEE SITE P IN UNIT IV WORK PLAN DATED <br /> Q DEPARTMENT USE ONLY <br /> Application Accepted By y�,.nj Date Issued ��'� /�� Area_ l//2l~JQ< 3 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> IF J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �r �lD2-1 DSS <br /> UNIT IV 6/23/99/sign bkpg/MI <br />