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WELL PERMIT APPLICATION Fr2M <br /> SITE ; <br /> MITIGATION <br /> X� it <br /> � -P 1 0 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) a <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> � 468-344.(209) 9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I; <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 Public Health Services,Environmental Health Division. <br /> Assessors., <br /> WELL Locatlon Cross Street City jjQ1A Zip O�l��Parcel# j91 <br /> PROPERTY Owner v �c0�1/c1 C Address_�n(� I✓L. �s City zip S7�7 Phone#L!S —4bS-� <br /> C-57 Contractor Address Z2, ityip�,zLYZwLic# �Phone# = Z7 i <br /> Consultant 15ub Contractor Address GityJ" Lic# _Phone# C�' <br /> r <br /> GIS Coordinates:X Y Township Range Section <br /> WOK 70 BE PERFORMED: <br /> QfIEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> WELL# 0 PRESSURE GROUT - <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "ONITORING HOLLOW STEM DIA.OF BOREHOL 'E i MULTIPLE CASINGS?1]YES TIO WELL CASING DIA: <br /> 0 EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS -7-h TYPE OF CASING: []STEEL QVC [IOTHER: <br /> fl VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL . t TREMIE TYPE TO BE USED: AUGERS (]HOSE <br /> Q AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED. ©Yes -&No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS:„_ 3 <br /> a OTHER: ]]OTHER APPROX.BORING DEPTH IZ BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? kQ (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, ules and Regulations, and all applicable.California State Laws. <br /> 1CTitleompany S <br /> Signed x f <br /> Date <br /> Print Name ''-7 — <br /> DEPARTMENT USE ONLY <br /> s . <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1 <br /> WORK PLAN DATED: ryry k <br /> `,C W <br /> Application Accepted By Date Issued LAleae <br /> Grout inspection By . l Date P Final Inspection y Date <br /> Destruction Inspection By <br /> DateVV _1 ] <br /> COMMENTS/CONDITIONS: wf rr <br /> Q-0 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# D BY DATE PERMIT 15ERViCE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Auth o sign ermit Encroachment doc 9/27/0 <br /> u <br />