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FILE COPY <br /> k WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor; Stockton, CA., 95202 <br /> (209) 468-3449 w / <br /> N(jN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATLO ISSUED �.V <br /> Application is hereby made io 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 /> WELL Location l .5'._ 1_�DrQd� Cross Street 2rA 1_nklty, - CZip 96ZC)to Parcel#o A 7'0,31•d/ <br /> ' itQ Q <br /> PROPERTY OWner6reoql e4 <br /> ak Addy r -bf _, City 1 rLrbC_L Zip b 2 Phone# <br /> C-57 Contractom63 j\L L Address_ -- /Jv►f �� CiI � I PJ # Z�D�Phone# -1��^�IaD <br /> Consultant 1 Sub Contractor <br /> d i iAddress `SM'arE <br /> Z28I Cit �Lid# ,�phone# 9215-7 C7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORME�I• , <br /> a NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) WESTRUCTION(choose type below) <br /> []SOIL BORING# VER-BORE <br /> 'Other, <br /> 0<PRESSURE GROUT <br /> COMMENTS: f Groupeccatons:W ' r <br /> bt 1 <br /> l <br /> TYPE OF WELL INSTALL TION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING [j;HOLLOW STEM DIA.OF BOREHOLE 4 MULTIPLE CASINGS?[]YES I]NO WELL CASING DIA-- <br /> [I <br /> IA:[I EXTRACTION []IAIR-HAMMER/DRIVEN CASING THICKNESS I TYPE OF CASING: STEEL p PVC. []OTHER: <br /> [I VAPOR [I iMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. []AUGERS 11 HOSE <br /> [I AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: ! <br /> 11 Yes p No (NOTE: MAXIMUM FREE FALL DEPTH IS 30) <br /> 0 SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 11 OTHER APPROX,BORING DEPTH [I BOLTED TRAFFIC SOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? {if YES,list specifications here]: <br /> "COMMENTS: <br /> II <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> I <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 Califomi State Laws. <br /> _ <br /> SignedTitle/Company � ��/'` j�p�- ,���� <br /> 'dntName �4 aDate <br /> DEPARTMENTLUSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> /GDS <br /> NORK PLAN DATED_ ii 2,e= a) <br /> -�pplicabon Accepted By__ Date Issued .45"2 Z "0 <br /> 3rout Inspection By Date Final frispection By <br /> ]estruction Inspection By Date <br /> ,OMMENTS I CONDITIONS:i- <br /> ACCOUNTING ONLY: RAID## <br /> PE CODES FEE INFO (AMOUNT REMITTED CHECK# REC'D BY DATE PERNtETlSERVICE RI:QlIEST# INVOICE <br /> D W it D. S•!-o <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> 120 �CCd � 8OQ1A Hl_=1I=[ � W EEb>r690613Z OT:60 100Z/5Z/Z0 <br />