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RDIIN�LUVO <br /> HECSY1LZn Joaquin County N01 9 -009 <br /> �.,)V I Eeldionmental Health Depart>rrWA,ARONMENTHEALTH SITE <br /> 3041✓ �bnAvenue,3rd Floor,Stockton,CA 9� IiT�SERUICES MITIGATION <br /> �� � I � : <br /> (209)468-3433 Web:www.sjgov.org/ehdIlk UNIT IV <br /> Well Permit Application <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 Title,Chapter 9-11JJ15.3 and the Standards of San Joaquin County E�nvironm[enat_al Health Department. <br /> WELL Location fil!`� Croas Street Si. City. J ►�►'1 Zip z5 Assessors <br /> S s�/10 tLle <br /> Owner <br /> PROPERTY 5 Address 2a (A!{I?(r /� 7 3" <br /> t, a <br /> 1 /_ _City p�Zip15202 Phone* !—y�J <br /> C-57Cor*actor U l�:u�cj f44�i�`d}W, Address.!35��� cityZip 151 Lldt 1�b7 Phone# 01' -q300 <br /> Consultent/Sub Cntr AS S ."r _ Address (A P�f(Cih/ ` Pr>o �3047 <br /> 6� � <br /> GIS Coordinates:X Y � Townshl c --~ C 93gZ <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> 0 SOIL BORING* 0 OVER-BORE. DIAMETER <br /> *Oho RESSURE GROUT <br /> ROUT SPECIFICATIONS <br /> COMMENTS: �,(�f G / S <br /> TY INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_ t11 OTHER APPROX.BORING DEPTH 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 Ordi ,Rules and Regulations,and all applicable California State Laws. 7� <br /> Signed x _�Q f Title/CompanySf/J I' c _s 1-nvi�✓1 HY^�'��►l?, <br /> Print Name 5_zL4y l L- !J i rT i°1�1 Date /_r0_(J y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADDRESS: 10-3 Al. S focktxi' 1-.0. P, SLS -. Is�U"-- <br /> WORK PLAN DATED: �/ �� Q too <br /> Application Accepted Bya/C/SAr��f Date Issued_ 1112-711)q Area <br /> Grout inspection By Date inal Inspection By t Date <br /> Destruction Inspection By Date Z !� <br /> COMMENTS/CONDITIONS: LOP <L&R AJFA P%_- <br /> ACCOUNTING <br /> Z/ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK f RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v- SR#4.5" e <br /> C-57 WC -WAIVER.,,_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />