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WEL'rPERMIT APPLICATION PbRM 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) 468-3450 <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 /> t;ourATY CrCVATKOVjE SAN ToACtv?N Assessor's <br /> WELL Location tZ2 . W E 41r R AVE, Cross Street S T R L G.T City 5 TO C K TOW Zip 9 510 2 Parcel# <br /> !AO TOAQVIPI G0tiN Y <br /> PROPERTY Owner FACILITIES M(vMT. Dr-PT- Address 1122 E. SCOTTS AVE, NCity_StOCKTON ZiP95205 Phone#(209)►f68-335} <br /> 0-57Contractor 14ITCHELL DRILLIMGAddress I%IS hILA119 WAY cityCOftbb Zip9S610 Lic#612611 Phone# (916)631-3583 <br /> RAMhG ENV. KANC4to <br /> Consultant/Sub Contractor. Address P-0160X 8 6 9 City My R I� A Lic# 9 D S ro Phone#_(916)351-32 so <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> (3) 1 WELL# MW- I s MW-L MW-3 a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: THREE 04-SITE GRDVNlDWA-TEK MOM1TORIN(r Wr-M <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE `IN MULTIPLE CASINGS?o YES ENO WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS Se44 4 d TYPE OF CASING: n STEEL I PUC p OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL G- F T. TREMIE TYPE TO BE USED: J AUGERS QHOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 6 SOIL BORING a HAND AUGER APPROX. BORING DEPTH ZS- F T, I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? N 0 {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: 'Y certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California." <br /> TH APPLICANT L 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTION <br /> Signed x Title a Dale 2 O <br /> SEE SITE MAP IN UN IV WORK PLAN. DATED -+116 (ol <br /> DEPARTMENT USE ONLY B <br /> Application Accepted By Date Issuedy z1_ Area �/ <br /> Grout Inspection By Final Inspection By hate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# 1. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUESENUMBER INVOICE <br /> sg# as v 3 r 3 <br /> UNIT IV-6/1/99/sign bkpg/MI <br />