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COPY <br /> ` t . SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> �? 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.slgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION UPRR- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR R M D T IS D wD v 2 <br /> Application is hereby made to San Joaquin County for a Permit to Construct and/or install the work desvibed Is applicatlon is made In compliance vrilh San <br /> Joaquin Co Lin y Deelopment Title,chapter&1115.3 and the Standards o�San Iloagyin County Environ lal Health Department. <br /> Aaseaso Od <br /> Well Locatiod! z�O.Jo� s aro s Sireet r%��R � T x <br /> Property/ 1,r� � Som••'—_--- . —OIO- <br /> Owner ar OMid. afi'�lE/Yl rti/ dress S� '/9 ,SC�nr-2?city 4411 .}/i1rJ./1 Zip jjLWPhone# W--$$ <br /> ' C-57 Contractor /�� Address ,V. F--Cl J/7A/41- city W��/a✓/a�Uc;#1Phone3 _6�':�yay <br /> Consultant/Sub Cntr _ Address/ �i, _u ye City Lic# Phone J)O- <br /> Coordinates: <br /> r C <br /> GIS Coordinates:X �71�� �, =��_ Township � S Range—,_) /r-- - section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BEL W) <br /> 0 SOIL BORING# AVER-BORE DIAMETER �-'9 <br /> 0 WELL# <br /> ElPRESSURE GROUT ^ <br /> ❑'OTHER GROUT <br /> SP/ECIIFFIICATIONS_/ 1 <br /> COMMENTS: <br /> TYPE 4F WE.L INSTALLATION TYPE CONNSTRUCTION IFI ATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE rel O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING.0 STEEL 0 PVC 0 OTHER V <br /> 0 VAPORV093 / --- <br /> ❑MUD ROTARY DEPTH OF G UT SEAL ^-7TREMIE TYPE TO BE USED❑AUGERS J9HOSE <br /> ' 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROAT SEAL PUMPED:0 Yes/J No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> W N <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS V �+ <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH ___,J�(/���/ <br /> nA TOR WSING PROPOSED �+ D BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> COMMENTS: (Ir YES.list Wr"Orn in mmmsnt carom) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 I hereby certify that have prepared thi application and that the work will be done I accordance with San Joaquin County Ordina ces,Rules and <br /> Regulations,a all apploble Ca mla Less. <br /> Signed TOIe/Company. S7` <br /> Print ame <br /> r Q Dale r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 2-6 Q 9 <br /> APPLICATION ACCEPTED BY DATE ISSUED ARFJa <br /> GROUT INSPECTION BY FINAL INSPECTION SY /aZz P <br /> DESTRUCTION INSPECTION BY DATE 0 /� <br /> ' COMMENTSICONDITIONS: <br /> kACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED RECV'D BY DATE PERMITISERVICE# INVOICE <br /> o y 66.1OR5 3C0k •27 R#0 <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E�NfC�R�O�AGHMG�(ENNTTD(�OC <br /> ' EHD 29-01 I1I5A1(WFaI NN"�'� IOcL�RAP <br />