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' WEL&PERMIT APPLICATION F'dRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT 11! <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> Joaq m unty De�fdopment jitl ,Chapter 9-1115.3 a)nd the S nd`as oaf San J�oa�uin Co ty Environ enta Heaith Department. <br /> WELL Loca n / lA �j Cr treet Ci ip Parcel# <br /> PROPERTY Owner �Gv Y1 A,{ddress �///V�� /� � ty � Zp Phone# X37 ,"e3D <br /> C-57 Contractor `S I ll,(_Address m 9 �� / Gt��)� /`1NCQity. h tt���p�lc# D Phone# !: <br /> Consultant/Sub Cntr l9-67 1E Address 937 S k��CIh;9V t Lic# X227 Phone# Zj;,9 b /Dy6 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> —AIZOIL BORING# [I OVER-BORE <br /> WELL# PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE. ' MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA-A/4 <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AAA- 1 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> Q VAPOR 0 M D ROTARY DEPTH OF GROUT SEAL IGO/y cam--.- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> Q AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: ' Yes�g-M NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 1]OTHER:_0 OTHER APPROX.BORING DEPTH / BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. �1 <br /> Signed x C�'�p� �T^� / Title/Company GtF2117 J A &5- <br /> Print Name {it//_ !�`� /�j/y <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S�- <br /> WORK PLAN DATED: Lm 7_ <br /> Application Accepted By t Date Issued l / -e Area <br /> Grout Inspection By Date mal Inspection By ate i) <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �k <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />