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WELL APPLICATION I", <br /> SITE <br /> MITIGATION <br /> SAN'JOAQUIN COUNTY <br /> ENVIRONMENTAL-HEALTH DEPARTMENT (EHD) UNIT IU <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202.," <br /> (209) 468-3449 <br /> P <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 9-1115.3 and the Standards of San Joaquin County Environmental Health.Department. <br /> WELL Locationlo L � Ci Cross Street � � <br /> Assessor <br /> s <br /> .� �._ ty��r�[�Tnl zip ,] G <br /> PROPERTY Owne 6 Address 74 4. (I'DOPo "S'T�CitySTrLe�ro zip-21-11 y"Phone#`� 2 7 <br /> C 57 Contractor sr Address` 2kl'B-RGuwA 7_City C_UtbQ& Zip S Lks#F . �7 hone �C� 10� 7 <br /> Consultant/Sub Cntr _(0V 6f,)4", Address 837S1(*.,) City, Ljc#62VWOZ27Phone# o7 o <br /> GiS Coordinates:X Y Township .... Range Section g, <br /> WORK TO BE PERFORMED: �! <br /> 0 NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> 0 WELL# W� PRESSURE GROUT <br /> /� <br /> *Other: �{ �Utv�Lr7-y2r,�(L� W L Grout Specifications: FZ1je6-091 b 1TE " <br /> COMMENTS 7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[j MULTI-LEVEL?0 WELL CASING DIA: <br /> EXTRACTION : <br /> � 0 A€R HAMMER/DRIVEN �! CASING THICKNESS TYPE OF CASING: �STEEL '0 PVC 0 OTHER:• <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:=MAXIM UM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE 1 <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): ` 1 <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 prepare this application and that the work will be done in accordance with San Jda'quip <br /> County Or c a Re U ons, and all applicable California State Laws. <br /> Signed x " �7 + Title/Company -r . pl1 Y.�IV �It� AL <br /> Print Name 7,J�I L L p • al.�[�+ Date <br /> ,.. DEPARTMENT USE ONLY 7c �;. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / I `4 <br /> Application Accepted By Date Issued ! _ 2L Area <br /> Grout Inspection By Date Final Inspection By / T Date" <br /> Destruction Inspection By Date - f <br /> COMMENTS 1 CONDITIONS: ,k <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK#" RECD DATE PERMIT SERVICE INVOICE <br /> jig 2 2L <br /> IZ 333'30 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign-permit Encroachment doc "8/29/02 <br /> s a <br />