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°aqutN'•.o� � SAN JOAQUIN COUNTY • ���� I <br /> __ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> fl ll <br /> 600 East Main Street, Stockton, CA 95202-3029 p�II �ION <br /> w✓ <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siclov.org/ehd NO V U V <br /> Gii:aPN <br /> WELL PERMIT APPLICATION ENVIRON <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Develo ment Tl Is, ter 9-1 15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> t ro �' Assessor's o <br /> Well Location rocs Street Harney City Lodi Zip 95240 Parcel# OSp /3 d / / <br /> Property <br /> Owner `O L7 Y12t )PX Ud es /I h '5 Adoq4"`U',6ty ,V <br /> ^ Zip S.Zf-(hone# <br /> C-57Contractor fJ.;1 O.rk,d-1nScv��cSsac,Address `kOZ- IvJmS+ 1 Wiaj Cityl„e(�-- Lic#449—m hone 3(9-t `3-t-o <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELU13ORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> IXSOIL BORING# 6 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> El 'OTHER nn GROUT SPECIFICATIONS <br /> t�r61n 1n...e.— <br /> COMMENTS:. 9A&t 1-r4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> XSOILBORING (,HAND AUGER GROUT SPECIFICATIONS l--d.N`�e rl / �.Gviy-p/f 7 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH IQ / ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specritulons 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 P Title/Company Project Scientist/Neil O. Anderson &Assoc. <br /> Print Name Abby Racc Date 11/6/nA <br /> 1 e ^,DEPAR'TM-ENT USE JOJN�--LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:'i S. CAuL,e c- kA..') 1VI1 <br /> WORK PLAN DATED: b ry� <br /> APPLICATION ACCEPTED BY DATE ISSUED/� �,6 D93 AREA-77 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY d'� DATE <br /> DESTRUCTION INSPECTION BY A / DATE If{ <br /> COMMENTS/CONDITIONS: r3>( CI✓�-t- sA —/��^'�`"� A j L{S�f ;1'�00 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> SR# ooSfkL <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2e01 11IW7(WEB) WELL PERMIT APP <br />