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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-04D) <br /> 304 E. Weber, Thlyd Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> TE ISSUED <br /> N N•REF NDABLE PERNITr , rCatipn is r lade in ecrnpliance with Sar. <br /> Application is hereby made to San Joaquin Coun y far a permit to construct and/or install the work d_scsH_ l This ce <br /> Assessar5 <br /> .�oaquin County Development Tittle,Chapter 9-1116.3 and tF.e Standards of San.bagtlln County Puh[Ic Health SeMces,Envlror rental W.ea1:h Division. <br /> /� �_Cro�sStroetAt, lZc� _City zp �Parcet#_ - <br /> 1NEtL Lecatlo t g�f��1�U/z -- �� CiN�-�1t- s+ 7�p 2 Phone 4? -1614 <br /> PROPERTY Owner 1[- lu Address 10 /Ur <br /> CST Con tractor,L�oc.�ftJw► <br /> �-Address 6S W% testa C{tY S� �P. 4 c'�St 26 P".Dile <br /> Consultant I Sub Contractor <br /> Address l4 rN S Citi fsr [�►u Lich =: Phcne4 $ <br /> GIs Coorcinates:X_,... Y <br /> .Township Range sect'Lr <br /> WORK r RE PERFORMED' oESTRUCTION(choose type below) <br /> lE-oj WELL?EORINS(CP-,GEOPROEE,HYDROPUNCH,HAND-.4lJG=R,OTHER') a OVER-SCRE <br /> [j SOIL BORING a 0 PRESSURE GROUT <br /> VELL <br /> Groat Specifications: <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION f,QNSTRUCTION SPECIFICATIONS it <br /> `TYPF OF WELLRING NST LL ATI STEM DiA.OF BOREHOLE��MULTIPLE CAS,NGS7 0 YES 0 NO WELL CASING DIA: _ <br /> �a EXTRACTION [;AIR HANIMER:DRIV=N CASING THICKNESS$L(n t{�__TYFE OF CASING: Q STEEL )(PVC �OTH.R: <br /> []VX-OR U MLID ROTARY DEP i H OF GROAT SEAL_ TREMI E 7Y-E TO BE USED: NraUGERS �HOSE <br /> p AIR SPARGE (]PUSH POINT GROUT SEAL PUPPED: 9yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (I SOIL BORING 0 riAN:�AUGER GROJT SPECIFICATIONS: <br /> OTFER:�D OTHER A=PRCX.BORING DE.'TH <br /> BOLTEe TRAFFIC BOK or a STOVE PIPE <br /> CONDU, aR CASING PROPOSED? isX�__(s ym listspec,ncatierts here): . . .- <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or Ina uleS and Regulati ns, and all applicable California State Laws. <br /> Signed x TitelCompany W •S Ad I <br /> B <br /> lo- <br /> Print Narne+Cv�n" C-,QnjP U Date 6,11tial <br /> DEPARTMENT USE ONLY NOE COPY <br /> 1 . <br /> SITE MAP IN UNIT IV FILE, 17DRESS• �o c 1s <br /> WORK PLAN DATED: I o 101 <br /> Date Issued G Area <br /> Application Accepted By <br /> �, <br /> Grout inspection By Rate 6 -Z11 c 1 Final Inspe=lon sy b Zo b Date <br /> Destruction,rcoecticn By Date <br /> COMMENTS ICON DITION& 1 � 5 � td j ` J <br /> ACCOUNTING ONLY: AJ D# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK 7f REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> sc� 4 �39t r�o : ckn�6� G 5 zs ar o26a, �5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc9/27/00 <br />