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WELL ERMIT APPLICATION F ZM 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 /> Aoplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance wit <br /> an Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division <br /> 1 / S! o r a o <br /> .TELL Location I rytS /igmrlkr L r E Cross Street f, ✓e City SfoC,k,foY Zip 9Sa15 Parcel"-_ /l{ <br /> FL <br /> ROPERTYOwner�cwa� 1r`�vi,I 15--.k/ P--SQ Address/GTS ti�ch�•��s 8W. Cityld.P-I,Ee-,6 Zip 33401 Phone: v Z-33;7 <br /> -57Contractor SnTri. .� ppLf�I+r.'.h �c, Address6i WIJW4 � Jnvl_ Citys�� l,. Zip9�a6 Lic"-SIaa6�Phone"-�a_�11L5 �� <br /> onsultant �uoFla�� oil EmyirrnrA1l4.rJAddressl400ProvId0l }. 11;1�wryCity lVoluood Lic# — PhoneTLwI nr-091) <br /> I$Coordinates:X Y Township - Range — Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, KANO•AUGER.OTHER') o DESTRUCTION(choose type below; <br /> a SOIL BORING# 0 OVER-BORE <br /> / J WELL* t7 Q PRESSURE GROUT <br /> 'Other. p, :ll �'y �f h u��OW Sf'2 j r c.vg o rs l / <br /> ;OMMENTS: N,,nj�or'n9 0,(IS i/�S�r.II�d 4-o o?0-3 a -FQQ ' belou S�r1Pr;Ce Sri-cI i . <br /> -YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ri <br /> ,MONITORING I HOLLOW STEM DIA, OF BOREHOLE $.1 MULTIPLE CASINGS?0 YES ,NO WELL CASING DIA: a <br /> LI EXTRACTION 0 AIR HAMMER/ORIVEN CASING THICKNESS Sck. Ll0 TYPE OF CASING: 0 STEEL r PVC a OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I✓c I f 1-a Qrfi TREMIE TYPE TO BE USED: li AUGERS OHOS- <br /> oSPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes !J No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> BORING 0 HAND AUGER APPROX. BORING DEPTH 15�r d �'`ti•x� e BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS-REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that 1 have prepared this application and that the worts will be done in accordance with San Joaquin County Ordinances,State Laws,and R,jli, <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 wort' <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 /> ,ontracting signature certifies the following: -/certify that in the performance o/the work for which this permit is issued. I shall employ persons subject to <br /> YORKERS'COMPENSATION Caws of califomia.' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN 'ADDVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed X_ 1� �/2"� / Tide/Company V rlTec�hicn)/Si/✓i!<S ll .Invlroh+«r r• tjnr✓:rr_i��r. <br /> 'tint Name_ �2•,so-. I`. t7avlc� Date v/ l <br /> . —� _ <br /> SEE-,SITE MAP:IN -.UNIT IV:.WORK;_. e--PLAND TED_ ;' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PF COOES FEE INFO AMOUNT REMITTED CHECK"- REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S <br /> 1/18/2000 <br />