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�� V n!San Joaquin County 40 <br /> v vironmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> 1 5 9069)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> #10WENT HEALTH Well Permit Application <br /> PERMIT/SERVICON-REFUNDABLE PERMIT EXPIRES t 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heahh Department. <br /> n e:i 94,t 6+112 \\ Assessors a <br /> WELL Location//q0/ /U Dov is kd• cross street ?Load cityLo O 1 Zip RSal4a. Parcel# a 10- o 0 1 a r` <br /> - 003 <br /> PROPERTY _ Lod <br /> Owner Mar+'t( fory:114 Address.-h 3(o3 N. Do\i%%g8ciry t 7ip95a4 phone# t` 'l - O I'-1\ <br /> C-57 Contractor?(- a c.ts'ton�°mflAderesa\081 e ex five. cfiyR'�cb(n°^a. 99$01 //3(038 Sto - <br /> Lp Lic#f0 hone#237 — `{575 <br /> Ste.A 707 <br /> Consultant/Sub Cntr 1S EfiQlnee�r,a O Address OS �'Ir� Cky vi Lic# Phone# 447-40aS <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> J NEW WELL/BORING (CPT,GEOPROBE, YDROPUNCH HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> J SOIL BORING# .3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS � `` <br /> COMMENTS: 33 6a 1 50'\\ Sarn Qke anc� )i oJrpb 4Z,O sc' vOle- -S[�CC' eoc-\' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLEx 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Li(o V. Ce rn e.(A-4 LA /. by cy�Dr1y e. <br /> 0 OTHER: (]OTHER APPROX.BORING DEPTH Ij 5 / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 in accordance with San Joaquin <br /> County Ordinances, R sand, Regulations, and all applicable California State Laws. <br /> signed x �._XJC� Title/Company 6n Vi(orw-nerI of A%eSSoc /KC. Fl�tnees�� <br /> Print Name hr\V 1_e e. Date 3- \S —0S <br /> DEPARTMENT USE ONLYSITE MAP IN UNIT IV n / <br /> WORK PLAN AED / <br /> FILE,ADDRESS:5 t I L a W I / A a.0 [3 DATED: of L J <br /> Application Accepted By 'Y1'i e A Date Issued [l ' �-S Area R <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aqO I $ � 3 t3 aos SR# 4U <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />