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SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT NIITiGATiC3' <br /> f UNIT IV <br /> 600 East Main Street, <br /> Stockton,3433 WebOv sQov oralehd <br /> Telephone:(209)468-3449 Fax:(209) <br /> WELL PERMIT APPLICATION <br /> work described. This application is made in compliance with San <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRONT DATE ISSUED <br /> permit to construct andlor install the cl'Sk-C�0 t <br /> Assessor's <br /> Application is hereby made to San Joaquin County for a pe Parcel# ? <br /> County Development Title,chapter 9-1115:3 nd t�e,Standards of San Joaquin county Environmental Health Department.. <br /> Joaquin [ � � 4`+ Ciry '--Zip <br /> x +"' `•). {�41i1f�ross�tr et 2tz� -�1h <br /> MOH+1.eG A Zip__q_. `Phone# _——s-- IA , <br /> Well Location � � ,n _ City�_— �} on jt�j-`fit � <br /> L O alit 50e^ ,tl �- f `atJ. Lrc# w� Phone <br /> ProPe�W}tt1r��Y- _ Address Zlp <br /> Owner C pct VIA City �QZ <br /> ` f <br /> (�I(aC rl�l 1 <br /> Address t �`� rl xKt(�t1� Phone 1-T"C-57 Contractor i V City Lic# — +rf at Address t� (�^ir� Range � ctlon <br /> onsultan ub Cntr �3 `ownAh,) <br /> Y <br /> GIS Coordinates:X <br /> DESTRUCTION(CHOOSETYPE BELOW) <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH_HAND-AUGER.OTHER') 1 ' RESSURE GROUTS ,�� ��- <br /> ❑SOIL BORING# NrpGROUT SPECIFICATIviJj <br /> WELL# 1100 <br /> i E <br /> C]-OTHER 1 CL E`` <br /> 4LiiC'zx1'1 kfwl }C.cr-� (� <br /> K�n .Y , <br /> COMMENTS:SiE-""�' ' <br /> t� <br /> INSTALLATION TYPE CONSTRUCTION SPQEGIFICATIONS <br /> TYPE��L DIA.OF BOREHOLE 8, E3 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> p'HOLLOW STEM <br /> MONITORING W �`iIL TYPE OF CASING:❑STEEL K PVC ❑ OTHER <br /> []AIR HAMMERIDRIVEN CASING THICKNESS_�—j <br /> ❑EXTRACTION x TREMIE TYPE TO BE USED AUGERS�HOSE <br /> ❑MUD ROTARY_�-DEPTH OF GROUT SEAL <br /> VAPOR �+aj j Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑AIR SPARGElOZONE Cl PUSH POINT(GP OR CPT) GROUT SEAL PUN <br /> GROUT SPECIFICATIONS <br /> ❑SOIL BORING ❑HAND AUGER�— ` � ►t BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: APPpROX.BORING DEPTH 't� — t YES.•i3 a u 3t:o: omrw c bon, <br /> ❑OTHER:�-- �, t(CTOR ti 5tNGPt Rt7F� 4 _�..• <br /> COMMENTS: •" YILArtt '�rh; <br /> ;3r o`s'� t EaIRE AGGESS AGREEMENT OR ENCROACHMENT PERMITS}�;' j"I <br /> ( ;. <br /> TE; OFFSITE BORINGS RE i �i' r <br /> 48 WORKING HOURS AIOTICE REQUIRED FOR INSPECTIONS !�-} <br /> 1 hereby certifytthat I hast- repay d this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all apps a le C Iifomia La 5• I> L 1<I I-4 <br /> tit` rpl 4, Title/Company <br /> 4 �'O' +rl L <br /> Signed + t Daae 7 <br /> Print Name' <br /> p' _IwDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> '• JO '�� W �W� v�U I ZL':� Y <br /> WORK PLAN DATED: <br /> J'Y�+��- T -- DATE ISSUED (0L�! c9� APPA <br /> APPLICATION ACCEPTED BY ---'� <br /> FINAL INSPECTION BY Dn7E <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSIC ONDITIO NS: <br /> ACCOUNTING ONLY. FAID# � -rC <br /> PE CODES ! FEE INFO AMT REMITTED CHECK at RECV'D BY DATE PERMIT/SEERVVIICE.IEi YiVOICE <br /> c=sib` wr A) c =_ _ <br /> �o ,ts) oRi.,; <br /> TION TOS/�N <br /> (6,--,4 <br /> rN ROf1CHtil�Nroa��� <br /> W. p <br />