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'r <br /> V Son Joaquin County �J <br /> Environmental Health Department <br /> 600 East Main Street, Stockton, CA 95202-3029 1 ATION <br /> • (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd JAN 1 1 . IT Ill <br /> Well Permit Application ENWRO FAT W <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 County Environmental Health Department. <br /> WELL Location 6� }h(liiillt?�it �CnO r {�ose Street City Zip 6 Paroe org d' 1�"d•Z <br /> Owner,PROPERTNtL-�- J,`� Address �� M Wfed Clty�Zi� Phone# <br /> C-7 Contractod%)i U&I i h wr Address 39DA12saACtty AC p�Lic#%1 Ophho- <br /> Cor=ftant 1 Sub CntrAtyV, 6e & 0, Address 437 SLYw ' � City 5 LIQ- ZPho WC)v <br /> GIS Coordinates:X 'Y Township Range Section <br /> WOOS TO BE U8EQMEj2,- <br /> p NEW WELL/BORING (Q,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHERS DESTRUCTION (choose type below) �I <br /> o SOIL BORING# OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> p"Other - - GROUT SPECIFICATIONS 6 G ah <br /> COMMENTS: �C-- rl _ ltl�-- �lO `�' r� 5SUIe iD 1 QIJt�I S <br /> e <br /> TYPE OF!+ML INJMLLA710M TYPE MNSTRUCTION SPECIFI9MONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL p PVC a OTHER: <br /> a VAPOR u MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS p HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING u HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER:_II OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinan I,Rules d Regulations,and all applicable Callforrlla tate Laws. <br /> Signed x � -. - ---Title/Company <br /> t�4k(bylpGef� o IS�- <br /> Print Name g rtan Jt'`t � MQ►� _._.. _ bate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6.1-5Z 7- &jaL,,z,,6 (&!:�I;2 2-05' Linn I JU <br /> WORK PLAN DATED: 11LIto <br /> Application Accepted ByDate Issued l I Area <br /> Grout Inspection ByDate Final Inspection By. ,p-, Date I Z-1 Z2 <br /> Destructiort Inspection Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> �_ .7 LI (,�,� I/L �o SR# [ 0 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit s/Encroachment doc <br /> ow29-omni WEB <br /> 9/1112007 <br />