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11-10-GCIYJYJ 1G•YJ4f-I'I r-MLAA l U ✓JJ <br /> • • <br /> WELL eERMIT APPLICATION FGRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 It. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EX IRES 1 FROM DATE{SSUED <br /> Application is hereby made to San Joaquin Comity for a permit to construct and/or install the work described- r h s application is made in compliance with San <br /> Joaquin County Development Tide,Chapter X1115.3 and the Standards offSSan Joaquin County Public Health Services,,�Environm Aall e�t Division. <br /> Ion. <br /> s Qyi Cross Street!lei SR f City 54���oYJ <br /> WELL Location <br /> u rl; }o„ Nor¢ktr� 5��7� �l�J !; CUJ�fPcltL t7 2_City D t� onef>��J9�3FC�` v�z <br /> PROPERTY Owner re SAL G' Address Zi ?Yd Ph <br /> / / �( Q <br /> ' �w l r 17 r.�� ., Address City i U'S� Zip�Lic4l / O0� Phone#��/('�/ <br /> C•5T Contractor/�i�, // <br /> Consultant/Sub Contn3ctor <br /> 7QL AddressSD�� �omD91C;Q1 ACity�o Lic#rvg6Phonc mss , G lZvo <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO IRE PERFORMED: DESTRUCTION(choose type below) <br /> i]NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) 0 OVER-BORE <br /> 13 SOIL BORING# 1]PRESSURE GROUT <br /> §WELL# tdlv-? MdU-2� NUj 4 <br /> Grout Specifications: <br /> "Other. <br /> COMMENTS: <br /> TYPE OF WELLINSTALLATIQN�Yf'E CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA-OF BOREHOLE 'w cot MULTIPLE CASINGS?ii YES a NO WELL CASING DIA: �eG <br /> EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS-El- 1/0 TYPE OF CASING B STEEL &PVC lI OTHER: <br /> 11 `rl TREMIE TYPE TO BE USEO-, *BAUGERS 0 HOSE <br /> p VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_ — <br /> No OTE: MAXIMUM FREE-FALL DE 30') <br /> AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED: I]Yes q� (NOTE: <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: /��` <br /> � <br /> OTHER_ APPROX.BORING DEPTH_ _ C� f BOLTED TRAFFIC BOX or i]STOVE PIPE OTHER: � — <br /> CONDUCTOR CASING PROPOSED? /t/0 (if Y'ES,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 /> hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin <br /> County Ord- an es Rules nd Regulati s,and all applicable California State Laws. <br /> �,, Title/Company �e��� *,- <br /> Signed x <br /> print Name /r'l�Q-y `�11-,.�,ll�l �U Date i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> y^ <br /> Application Accepted By Date Issued <br /> Date Z O <br /> Grout Inspection By Date 2 i © / Final Inspection By <br /> Destructlon Inspection By Date <br /> CQMMENTS/CONDITIONS: <br /> lACCOUNTING ONLY: AiD# <br /> �E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/0( <br />