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- WELL PERMIT APPLICATION IRM SITE <br /> MO� MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNIT IV <br /> SAN 2 3 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> „jNMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> tRMITISERVI'IS (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 County Public Health Services,Environmental Health Division. <br /> n o 1,,�''a Assessor's �1 <br /> WELL Location ('�Yl Lf nil rPv_t[ Cross Street iiy Zip (�Parcet# <br /> PROPERTY OwnekhWM_ t". dress 4 ' Ci Zip`IPhonGj <br /> C-57 Contracto Address 1 Ci Zip I��Lic#tbl�)iVDPhone "t- n ky� <br /> Consultant I Sub ContractoF1:4' a Y iTX�ddressN lt�ul� Iw Ci� ��_ Phon 0// <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> JEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER' Qp DESTRUCTION(choose type below) <br /> Q SOIL BORING# Q OVER-BORE <br /> NELL# S PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI A� TIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL [JPVC (]OTHER: <br /> Q VAPOR I]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> Q AIR SPARGE 11 PUSH POINT GROUT SEAL PUMPEDes jj No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING I7 HAND AUGER GROUT SPECIFICATIO <br /> HER )(Q OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O % ces, R egulations, and all applicable California State Laws. <br /> Signed Title/Compan VL <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By � t Date Issued -7 d a`J Area <br /> Grout Inspection By Date Final Inspection By'' Date <br /> Destruction Inspection By Date <br /> COMMENTS ICON DMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> CO 39Vd a00-1A HIAI3 ££b£891760Z L£:£T 000Z/t70/ZT <br />