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San Joaquin County <br /> AL <br /> IF <br /> Environmental Health DepartmentA�, MATE <br /> 600 East Main Street, Stockton,CA 95202-3029 JAN I t 2AITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 1W <br /> Well Permit Application ENVIRONMENT HFQITH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER11' ERVUS <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application Is made In compliance with San <br /> Joaquin County Development Title,Chapter 1-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> Locatlonasp buslKss � ross Street AZi 9Iy 03 <br /> PROPERTY p p ^� v <br /> Owner U lri dress `b & III_- ! City zi 5 70 Phon �35 1� <br /> y Address 1 + C r %&7 Li�Pho <br /> C-i7 C�tkacter Ky�� <br /> CorrarMsrnt 1 sub Cntr 0.1 <br /> Address ��� �-ha,� City. -�I I n uo* �2 Phor <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BEEERFORMEOw <br /> 0 NEW WELL!BORING (Q,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) JOSTRUCTION (choose 15 <br /> D SOIL BORING# VER-BORE. DIAMETER <br /> 01fVELL# 0 PRESSURE GROUT <br /> D•pqr� ROUT SPECIFICATIONS <br /> COMMENTS: �(' } t /iAW;7 61 4 <br /> i 1 4 1 <br /> rya�Oa uu�r r INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE- D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE!OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 , Rules and-Regulations,and all applicable Callfornla tate Laws. <br /> inned <br /> Sx 7TftWCompany &J-f5516 P �ed <br /> Pft Name riarAAr /n Y1 Date <br /> A 9,0 V11 <br /> DEPARTMENT USE ONLY Fj <br /> SITE MAP IN UNIT IV FILE,ADDRESS: s" 2-0 <br /> WORK PLAN DATED: <br /> AppRcatIM Accepted By Date Iss 110 Area <br /> Grout Inspection By .+L o.+.. mow•. Date 1 Final Inspection By Date <br /> Destruction I B Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 350z *yAf I/q/14> SRS 501 14 f <br /> C-57 WC -WAIVER____ C-57 Letter of Authorization to sign permitvEncroachment doc_ <br /> tm 2m-ooi WEB <br /> 9/11=7 <br />