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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION 1 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> UNIT IV,. <br /> _ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 I,1 <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 Public Health Services,Environmental Health Division. <br /> L C f Assessors <br /> WELL Location__. _0t ul Crass Street S City 'r Zip'S 7-0Z Parcel# 133-O Sy—no <br /> PROPERTYOwner UAGk ! 1 „ a_L_Address-706 M. -k CiZip�2Phone# ZQAC YG5-2G67 <br /> C-57 Contractor �yi -Address 3�� (C!ty� ip L� Lic#hone#-� °� `�Zo�'Pc3 <br /> Consultant/Sub ContractorA kLA�r o1 CV A-' ddress_637_�&94{4k-W City-49Ci- Uc# ZZ- Phone# ZOq (tC7--f(JOC <br /> GES Coordinates:X Y Township Range Section' <br /> WORK TO BE PERFORMED: <br /> IkNEW WELL/BORING(CPT, EOPROBE YDROPUNCH,HAND-AUGER,OTHER*) ©DESTRUCTION(choose type below) <br /> ,SOIL BORING# 3 _ a OVER-BORE <br /> {I WELL# o PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ©MONITORING HOLLOW STEM DIA.OF BOREHOLE 2r` MULTIPLE CASINGS?Q YES-'NO ,WELL CASING DIA: PA_ <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL O PVC 11 OTHER; <br /> 11 VAPOR p MUD ROTARY OEPTH,OF GROUT SEALrTREMIE TYPE TO BE USED: I1 AUGERSY BIOSE <br /> p AIR SPARGE �nUSH POINT GROUT SEAL PUIMPED:,D -Yes p N❑ (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> r <br /> &SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:. <br /> [)OTHER: 0 OTHER APPROX.BORING DEPTH (ot7 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASIr.PRO OSED?-_(if YES,list specifications here): <br /> 'COMMENTS: 1 " <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 Or ' aces ales and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company Lk e <br /> Print Name 1 Date <br /> DEPARTMENT USE ONLY k <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1 <br /> Application Accepted 8 j LWe Issued Oc + Area <br /> Grout Inspection By Date nal Inspection By Date <br /> Destruction Inspection By Date +' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArtl <br /> PE CODES FEE INFO AMOUNT REMrrTEa CHECK# R C' Y DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3 "0 g 11 SR# Z 6 Z <br /> C-57 WC -WAIVER C-57 Letter of Autho z o An permit Encroachment doc 9/27/00 <br />