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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (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/or 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 San Joaquin Couunnty- Environmental Health Department.Assessors <br /> /' ross Street /�°'�rd �tiitY -/� Zip f;;20 Parcel#��� - "®3 <br /> WELL Location (' &I ��p'�p ' ' --''//—' <br /> i7�,,,� ��-vj Address —!r/,/y0(aYse 4/e City O u7V ZipTy?P7Phone# 4115 �.� �lgl <br /> PROPERTY Owner�v, ^ d <br /> ` L/ City, . �cMaj' Zip�c#Phone# 4 711 APO <br /> C-57 Contractor f/� ��'����� • Address �f90� �X/� nay �� y,2 f3 <br /> / AA <br /> Consultant I Sub Contract <br /> Section/�Qt[ �'+i!l� Address��37y,enf a Ci P Lic# Phone# y Dig �3 <br /> Section <br /> GIS Coordinates:X <br /> Y Township Range <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> �1Q�W WELL/BORING(CPT,GEOPROBE,HYDROPUN�H,HAND-AUGER,OTHER`) 0 OVER-BORE <br /> /" �-FOIL BORING# .,f 11 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: Grout Specifications:A,,,-to f S <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 'VA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7D TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE USH POINT GROUT SEAL PUMPED: 0 Yes A]-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> -SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: C /p Ss � Merr� <br /> OTHER APPROX.BORING DEPTH /T f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O <br /> Qn +� CONDUCTOR CASING <br /> QPROPOSED?�(if YES,list specifications here): <br /> *COMMENTS: Q <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 /> ared this application and that the work will be done in accordance with San Joaquin <br /> I hereby certify that I have prep <br /> , and all applicable California State Laws. <br /> County Ordinances, Rules and Regulations <br /> -�� Title/Company lees <br /> Signed x <br /> �rj'�d P PQM G Td Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> / �(��� Date Issued 7�/�b� Area <br /> Application Accepted By r\ Date Final Inspection By Date_ _ <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# rer�t <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/25/0 <br /> C-57_, WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_. <br />