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0 FLEWT <br /> WELL PERMIT APPLICATION FORM 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 /> (209) 468-3449 <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> WELL Location 990 B cknv+ Ave,nve, Cross Street Or,City_ Tra.c _Zip Parcel# Z 3 "4170-<C <br /> PROPERTY Owner_ M'11'lglei;c,h\ Address P.O. &,,x 60iZ City_5-'n Zip TliS-63 Phone# SLIZ-[.?13 <br /> C-57 Contractor Pre-i 5 i cn 5< nelon , le­. Address /Y00 5. Som S f-. City {c k,xarcj Zip 9,yt3o cl Lic#631v3$7 Phone# 5'10-237-yS 37 <br /> Consultant Sub ContractorGe­-iic4.,ix Cellsol&,ilS Address 2l0c Wetosfy SF. /7i`0,City Oeklnitd Lie* Phone# 5-10-"3-11100 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL 80RING CPT, GEOPROBE,HYDROPU NCH, HAND-AUGER, THER- 0 DESTRUCTION(choose type below) <br /> SOIL BORING# GMX- 171+ ov;ih CoMX 12 l2 D;rec SN bDfrr"(P 0 OVER-SORE <br /> 0 WELL# PRESSURE GROUT <br /> 'Other: D;rec-f PyS(7 C✓.fb. Env ccc 't s .v+P�;n� SysFtm �5<+.i<P'i-1�It Gab <j:� �ctcx_kl <br /> COMMENTS: ao �n<iq b bt ylc✓414 r/UM boNvrn 4o fv( tJi}j� a } <it n;�e- �ollcw'e< Soil 9/r ud1Ja�G� San.pll, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2.S " MULTIPLE CASINGS?0 YES XNO WELL CASING DIA:N A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AI JA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL to iokt A14ft . TREMIE TYPE TO BE USED: 0 AUGERS "I-110SE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER APPROX. BORING DEPTH l S Z SI bin. a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_o OTHER CONDUCTOR CASTING PROPOSED? Ivo (if YES,list specifications here): <br /> COMMENTS: -111.,5 G.lo,lc i 5 Cvsicrt( � $c.laett, 1 r<r ?r� /�Qy 3 �Oo j uc �, 1-k JO 2o i <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'COMPENSATION Laws of California." <br /> CALL THE UNIT' VIMSPECTOR 48:.WORKING HRS.IN ADVgN:CE FOR ALL:REQUIRED INSPECTIONS. <br /> Signedx N G+�✓ Title/Company Staff e42&tza.ly 61MLSOt ,.�f$1 j,1c. <br /> Print Name Todd .J. Loa./ Date y�i216 1 <br /> /� <br /> I� a AP <br /> ��.��k.-..?S.-G.�c i .4.v. .,F•...-....LLaanssrx..�r.0 IQw..�auuC9,daF.. AW:aum W4 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By Date Issued —( —�� a <br /> Grout Inspection By IL Date Final Inspectiol D e <br /> Destruction Inspection By Date Z- d 2_- <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br /> C' •J <br />