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WELL RERMIT APPLICATION FICOM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <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/cr install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and.the Standards of <br /> San Joaquin County Public Health Services,Environme Assessor'tal <br /> WELL Loation Division. '2 <br /> Cross Street /I rClty �7?;&J_Zip Parcel# 6 3—.2�cV–✓�– <br /> �'/`��/C <br /> PROPERTY Owns Address ��/7 <br /> /�/pf���GC. d 4G�ddress�� w In 7 b Zip ?A Lic#4?e one# <br /> C•57 Contractor <br /> Consultant/Sub Contractor <br /> 1`1l� C.�l� Address9d7 City__-Lic# Phone# YYo7/°'A <br /> Y ,Township Range Section <br /> GIS Coordinates:X - <br /> WORK TO BE PERFORMED: 17 DESTRUCTION(choose type below) <br /> VNEWELL W WL/BORING(CPT,GEOPROBE,HYDRO PUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> SOIL BORING# PRESSURE GROUT <br /> WELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Qry_,�' <br /> �� MULTIPLE CASINGS?0 YES WELL CASING DIA:Nr <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> o EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: []STEEL I)PVC 0 OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes Q4 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: e BOL TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 26 D <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or nce , RaVand Regu ions, and all applicable California State Laws. U ( <br /> eo <br /> Signed x /1 Title/Company !/ <br /> ,qc Date Z <br /> Print Name /"y DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By� _Date Issued /��/ V / Area <br /> Grout Inspection By �D to <br /> yl d ` Final Inspection By —Date <br /> - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICER EQUEST# INVOICE <br /> 9 1 157 S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_. 9/27/00 <br />