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WELL PERMIT APPLICATION FCMM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> J ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 itle.Chapter 9-1115.3 and the Standards of <br /> San <br /> r+Joaquin <br /> ,/County Public Health Sew Environmental Asse sor'sDl7ivision. <br /> /N.Iifi / P%�C y-u u= ---Ci � ,eG9 Zip ----Parcel# /fid ZZC7'-OL75 <br /> WELL ocat <br /> Al 'g 29"'do's Cross Stree ty, <br /> �/_7 � Ci 5e4/>Cx1a Zip.. Phone�/(o <br /> Address <,e� s, SO ty-- < 9 <br /> PROPERTY Owner �%)7�/'U //�<�� �-'/�,-7� _ � _ <br /> ��1�/ 1� Address 7 iSA)1f.AL&f by city Zip��Lic �Ph°n <br /> ev <br /> C•57 Contractor " ('w//�y�7-� �— <br /> ///c-,i ) Address3b>-5-6 LYy�F City57 Lic# Phone <br /> Consultant/Sub Contractor��`— <br /> Township_. ___Range [Off_ Section <br /> GIS Coordinates:X Y - <br /> WORK TO BE PERFORMED: HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION Ghoosetyp elow) <br /> 0 NEW WELL/BORING(CPT.GEOPROBE, H r7 , <br /> SOIL BORING# O <br /> Il WELL# <br /> Grout Specifications: rQ <br /> *Other; <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I&HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?0 YES RNOp����W� ELL CASING <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL qty.VC OTHER: <br /> Q VAPOR MUD ROTARY DF�PTH OF GROUT SEAL 9 TREMIE TYPE TO BE USED�'AUGERS HOSE e <br /> FAIR SPARGE ❑PUSH POINT GROUT SEAL PUMPE . Yes (NOTE: MAXIMUM FREE-FALL DEPTH I ) <br /> o SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: AleitiJ��¢ TRAFFIC BOX or STOVE PIPE <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH :;Z5_1 te— <br /> CONDUCTOR CASING PROPOSED? AIJL (if YES,list specifications here): <br /> *COMMENTS: / /J IJ Cl/ L`�"S 'XS4 A / / & PI�Mr <br /> /t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> KING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 18 WOR <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 an gulationS, and all applicable California State Laws. r <br /> Title/Company-5--r. J "L <br /> Signed x 2 <br /> GC Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Area <br /> _Date Issued <br /> Application Accepted By Final Inspection Sy Date <br /> Grout Inspection By p Date <br /> Destruction Inspection By t Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> I <br /> 02 902, loo (90 C99 !1163 GGk i o2 po�o36 <br /> 9/27/00 <br /> C-57_ WCWAIVERC-57 Letter of Authorization to sign permit_.Encroachment doc_ <br /> = _ <br />