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SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> . '` 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> cL1�„�c7. Telephone: (209)468-3449 Fax: (209)468-3433 Web:www..s'gov.org/ehd UNIT IV <br /> G.Z; <br /> WELL PERMIT APPLICATION ' FILE <br /> FILE COPY <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 /> •r <br /> Assessor's <br /> Well Location = �J' CC{t'" Cross Street I ""'� sF' City :; ui, Zip 'l S w Parcel# i!� i L VC <br /> Property 9,e <br /> 1 <br /> Owner � t c Address r' ' S City Zip Phone# <br /> t ` City 1"C-57Contractor "'w LJ d Address yLic# a Phone <br /> uConsultant/Sub Cntr Address} Lit# Phone L <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER') IR DESTRUCTION(CHOOSE TyfE BELOW) <br /> ❑ SOIL BORING# ©OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑`OTHERt p GROUT SPECIFICATIONS <br /> COMMENTS: "��✓L� U�41y�= Lf 3_t fl I,J 4 , ct..r,( M(„i:? ff CP t;ha <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AER SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations/and all applicable California Laws. <br /> Signed Yr Titte/Com rd �'� { rr I / <br /> p y _ _ i t' U (�y�j j ,trVl rf,4^L� � Itnf. <br /> an <br /> Print Namesj/� 1�7 r <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE{SS: s ck+ <br /> WORK PLAN DATED: J a 0 0 <br /> APPLICATION ACCEPTED BY ? DATE ISSUED !O O AREA t4-5 <br /> GROUT INSPECTION BY "p 4 FINAL INSPECTION BY Y-C,-hr' DATE �0 9 <br /> DESTRUCTION INSPECTION BY fa /1 -&e�r� DATE 4-�/-(j�6 <br /> COMMENTSICONDITIONS: e 5 r U V -IV P- i aaA _3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVIC£# INVOICE <br /> 3502 60. 00 60. 00 20352 SR#00sG99 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11ISR7(WEB) WELL PERMIT APP <br />