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k.JSan Joaquin County <br /> Environmental Health Department eals <br /> SITE <br /> +� 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 � ATION <br /> (209)468-3449 Fate:(209)468-3433 Web:www.sjgov.org/ehdoc] IT IV <br /> NIP G <br /> o� Well Permit Application E r0�j� ZO�s <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDE�MIT�SrT,` ��[� <br /> h`��v'�de'fn compliance <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatio pliance with San <br /> Joaquin County Development Title,Chapter g-1115.3 and the Standards of San Joaquin Coun Environmental Health Departmen. <br /> } Assessors <br /> WELL <br /> WELL Location s Street City Zip Parcel# 0 <br /> li <br /> PROPERj�g `� ' dress ����� +� Zip'��Phone*Owner <br /> ��r� <br /> v <br /> C•57 Contractor //�� City �y�Z�ip _ Lic# Phone# /� <br /> I Consultant 1 Sub CntrY-'T6� d s r -Cite-► a ic#aYOZZ7 Phone# DDQ6� <br /> E ' <br /> j GIS Coordinates:X Y Township Range Section <br /> i W ORK TO BE PERFORMED: <br /> EW VLL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 LL# a PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> 1 a MONITORING ©HOLLOW STEM DIA.OF BOREHOLE-Z&'4 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> j <br /> d EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS lv TYPE OF CASING: 0 STEEL 0 PVC d OTHER: <br /> { U.VAPOR a MUD ROTARY DEPTH OF GROUT SEAL REMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 11 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes,4 No. NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> /SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> r p OTHER: a OTHER APPROX.BORING DEPTH_ O —f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: C1�71 S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules nd Regulations, and all applicable California S to Laws. ti <br /> 3 <br /> Signed x J J ,!11� <br /> Title/Company <br /> Print Name 1 J��ti,�r'ca �(/!_ Date l` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 2 S • I <br /> WORK PLAN DATED: Z I�Q <br /> Application Accepted By i`?� Date Issued U Area <br /> r <br /> Grout Inspection By tltl Date Final Inspection By Date Z O <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> { 3 31yoa "o _. G ID ��o� SRI' d <br /> li C-57-_---- WC---WAIVER_ C-57 letter of Authorization to sign permit_Encroachment doc^ <br /> EHHD 29-02-001 <br /> 6122/04 <br />