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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' oy.or /ehd <br /> MITIGATION <br /> WELL PERMIT APPLICATION UNIT IV <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 San <br /> Joaquin Co5.unty,Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location_k�O-lSot=F I(/ Rt'"`cs l lnrt 2� _ <br /> Property I �U cross Street d IS 1.3 F11e� �f�� City Assessor's <br /> Owner «C Ma6�e / /'/'1 r5 Zip Parcel# <br /> n�^ Address bb`E �q �� City f'q(` �/� <br /> C-57 Contractor f�J }' '' ZIP��3� Phone#C209 'P-2 9.2 Z <br /> I �� Address 22D /V rqs�Sfi.�� M 'q� C Lic# QaYPhone S SiJ-66LA1 <br /> SACC City 2y <br /> Consultant/SubCntr Address �1 (bkL I �,k '✓ <br /> Sul'le �7�city r�.,� Lic# /1h <br /> GIS Coordinates:X 'T Phone <br /> ' Y ,Township <br /> WORK TO BE PERFQRMEp: Range Section _ <br /> 9 NEW WEL ORING PT EOPROBE YDROPUNCH,HAND-AUGER,OTHER*) <br /> ❑WELL 29 SOIL ORING#_� ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑*OTHER ElOVER-BOREDIAMETER <br /> ❑PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM ^� t <br /> DIA.OF BOREHOLE <br /> EXTRACTION ❑AIR HAMMER/DRIVEN El MULTIPLE CASINGS[jMULTI-LEVELWELL CASING DIA: <br /> VAPOR ❑MUD ROTARY 1 <br /> ❑ <br /> CASING THICKNESS- N=TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER N/a. <br /> ❑ <br /> DEPTH OF GROUT SEAL I =30_fQQ�TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ,PUSH POINT(GP RCPT)_ GROUT SEAL PUMPED:El Yes �/'I <br /> `QI SOIL BORING '' //�Na (NOTE:MAXIMU FREE-FALL EPTH IS 30') .�.. <br /> ❑HAND AUGER�_ GROUT SPECIFICATIONS NC-Ij, <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _ �j0 � <br /> COMMENTS: CONDu OR CA ING P OPOSED C1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> A/111 Iq[�(� Cl7 ('f YES,list specificatlons in comment section) <br /> , ,� Cot,- 1 artj, �e. t.Cc� /ic7✓ rt <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITSny F <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS h� <br /> I hereby certify that I have prepared this application anthat the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,�andall �jcable Califor�Laws�. _ <br /> ll� <br /> Signed p f <br /> Title/Company I �Oje( � G-010, f <br /> Print Name S q^ �� <br /> Date /Z2/0S <br /> v DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: y /„1 )�Q�� <br /> APPLICATION ACCEPTED BY /'d <br /> / I DATE ISSUED ( O�' AREA <br /> GROUT INSPECTION BY � <br /> FINAL INSPECTION BY DATE �/ �� Op <br /> DESTRUCTION INSPECTION BY <br /> DD-- DATE <br /> COMMENTS/CONDITIONS: —5-h ,,�,txeQ� t CA46_("d`-- <br /> d 1, <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMT REMITTED C <br /> RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> d n'ti.:`' l - q�2 s'0 F S R# p Soy <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) <br /> WELL PERMIT APP <br />