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I <br /> _ I <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN,COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL•HEALTH [DIVISION (PHS-EHD) <br /> 304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ' <br /> N N•REF NOABLE PERMIT TE ISSUED <br /> Application is hereby mala to San Jcaquin CCUnty for a permit to:anstruet and/or instal:the vrerk described. This application is rade in compliance with Sar. <br /> ,�oaquiri County::evelopment T itle,Chapter S-111$.3 and tr:a Standards of San Joaquin County Pu5!ic Health SeMces,Enviror rent3i Heai:h Division. <br /> _ l Assessor's <br /> WELL Locat[o,_?� f 1��_Qif�11i S ��y{�Croas StroeY City Z:p_`�aarcesJs <br /> PROPERTYCwner61&tMatsi Address�lO0C�;. < t�L� City .S f4-t zip SZOC Phonal - bi <br /> C-ST Contraacr NA,Con3uitant ra� Adcress Cly ickk L,,Fa4 L:c-�7A C F^ f <br /> Sub Coruor6za"W{ Ama4si lAdd,ess 1 l Lim Phcne# %E5 <br /> 84is, _. <br /> 015 Coorcinates:X ,Y - Township Range �ectscr <br /> WORK TO BE PERFORMED, <br /> C mE'01 wEi_l,r cr?.IPI=(CF",GEOPP,r]EE,HYDRpPLINCH,HAND-AUGER,OTHER-) XESTRUC7104(c.roose tyke below) <br /> G SOIL 8ORING x 0 CVER-8CRE <br /> VELE f1�Sp(lIu 1 _i N�FRESSURE GROUT <br /> Other: Grou:SpeciStations- AACA ce"W _ <br /> COM?Z EDITS: <br /> TYPE OF Ih'ELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ` ` ONrfOR:NG © -1OLLCW STEM DIA.OF BOREHOLE �5 rr MULTIPLE CAS NGS-, OYES 0 NO WELL CAS3NG DIA:_ <br /> a EXTRACT IGN (,.AIR HAM MER'DRIV=N CASING THICKNESS at-,46 _TYPE OF CASING a STEnL r;'vC G OTH_R: <br /> p VAPOR G ML0 ROTARY DEPTH CF GRC' T SEAL' -TREMIE-Y�E TO SE USED: p AUGERS p HOSE <br /> [I AIP.SPARGE 0=USH POIYI GROUT SEAL PUtiiPEO: a Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> [I SOIL DoRiNG G jA14:;AUGER GROJT SPECIFICATIONS: <br /> []OTFER: A=FRC)(.BORING DEBT-1 4.5� _ _�'OLTEC TRAFFIC BCX or D STOVE PIPE <br /> [ CONDUCTOR CASING PROPOSED? (:f YES,lis:spe-z:flcatkzs here): _ <br /> •CosZ'rENIS: dee Lvelk 1,Y" }'o; C� iI <br /> NOTE: OFFSITE BORINGS-REQU[RE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNi T 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. } <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ord" ante , es and Regulations, and all applicable Californiap State Laws. <br /> Signed x Tit elCcmpany J IGtf-F� n t i S r cUl�+ zem <br /> Print Name t Date CU <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '` I <br /> WORK PLAN DATED: <br /> Appilcation Accepted ev Dare Issued 12 0 1 Area <br /> CroutlnspeClcn By Date Z O Firal Lnspaalon By Date <br /> Destruction!rscecticn 2y Date <br /> COMNIENTSICONDITIONS: !� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 9 REC D BY O4TE PERMIT J SiaRViCE REQUEST INVOICE <br /> 3Dt- li <br />