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WELAERMIT APPLICATION FSAM SITE <br /> SAN JOAQUIN COU'°:TY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <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 Stand rds of San Joaquin County Environmental Health Department. <br /> � Assessors <br /> WELL Location 3 rN �� � �rCross Street -0 City° Zip Parcel# - <br /> PROPERTY Owner l.�5� l'� 'tx �+ Address 3d,'ce/ City tCvt Zip i3�0 Phone# <br /> C-57 Contractor !.j•' Address / sib City_-4Q ^-/Zip 9??Lic# hone# cll6 r <br /> Consultant/Sub Cntr' isPt//re dress Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CP ,�OPROBHYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> )KSOILBORING# 0 OVER-BORE. DIAMETER <br /> ELL# 0 PRESSURE GROUT <br /> "Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> co <br /> CIS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS k <br /> ,MONITORING AiIOLLOW STEM DIA.OF BOREHOLE �" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ' <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS `O%� Z`` TYPE OF CASING: STEEL "VT 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `Lt`&�aREMIE TYPE TO BE USED: IJGERS 0 HOSE <br /> f <br /> 0 AIR SPARGE/OZONE ,RUSH POINT(GP or CPT)GROUT SEAL PUMPED: es 0 No ( OTE: MAXIMUM FREE-FA L DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ��—� OLTED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company it amoral <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �5A--, <br /> Application Accepted B Date Issued t 0 U+ Area__ <br /> Grout Inspection By Date 2 e) Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br />