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WELL PERMIT APPLICATION FORM 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(209) 468-3449 O/V <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 appiicatian is made In compliance wth San <br />.Joaquin County Development Title,Chapter 9-1119 3 and the Standards of San Joaquin County Pubttc Health Services Environmental Health Division <br /> �t�_ s l dada Znd - P 9 ASg�sSarS/67*431e a <br /> UY>wLL Lacaffon S-��_--- Cross Street C! Zt 5��e Parcel# <br /> PROPERTY Owner6rewal_ i`Lp+r14F�fes x e4 aQ Add�)5,- r tom. r, c�ty_l f�_e.� -_ zip 3 2 Phane3;E �3 d�+ <br /> V �Ti 1C Address ( 45 W Crt C �3ip z* 'ZC6a#Phone# -1-1 <br />'" S7 Contractor_ t� "1-L#!oo <br />;ansultant!Sub Contractor ETIC E'C"Q(1` Qx Ad�res5 ZZB,S- D���a ct�hLt_z Phone# 4-7/0 <br /> VS Coordinates X Y Township Range Section <br /> vORK TO 13E PERFORMED <br /> I NEW WELL I BORING(CPT, GEC]PROSE, HYDROPUNCH, HAND-AUGER OTHER"} '% DESTRUCTION(choose type below) <br /> Il SOIL BORING# VER-BORE <br /> `�NELL#- Al l l 1�.- __ _ RESSURE GROUT <br /> Dther CC '' * Grout Specifications <br />;OMMENTS C�]el�� P Wzs fLU-3Z w,11 bz olpe. I t M W1 0 E&W MW�r 1v Qt Z s Zig 1 1-�)I ti GE DrE.sSI.rAeQ <br /> YPE� OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING []HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS'?jj YES 1]NO WELL CASING DIA- <br /> EXTRACTION f7 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 1]STEEL Il PVC U OTHER <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 13 AUGERS []HOSE <br /> AI !GE 11 PUSH3 POINT GROUT SEAL PUMPED []Yes D No (NOTE MAXIMUM FREE=FALL EPTH IS 3�'} <br /> SOIL ORING []NAND AUGER GROUT SPECIFICATIONS <br /> OTHER ❑OTHER APPROX BORING DEPTH U BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES, list specifications here] <br /> OMMENTS <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 /> iereby certify that i have prepared this application and that the work will be done in accordance with Says Joaquin <br /> runty Ordinances, Rules and Regulations, and all appncable Callforrtt State Laws <br /> nod x -T 7 f/ _� - - - - - - _ -Tlfle/Company r •�� ' r Q' en/<z— <br /> it <br /> /<it Name �Cq" D��' - - - -- - - - Date_ �`d��/ <br /> DEPARTMENT USE ONLY <br /> E MAP 1N UNIT ]V FILE, ADDRESS: 44R <br /> )RK PLAN DATED_ c1 <br /> kation Accepted 9 Date Issued � - ~0 Area V G �+ <br /> it lrispectron By. Date Flnai Inspechan By Date <br /> ruction Inspecoon By Date <br /> rMENT5/CONDITIONS- <br /> NGONLY AQ# <br /> CODES FEE INFO AM011,1N`r REMITTED � CHECK# REC'D BY DATE PERMITI SERVICE REQUEST* INVOICE <br /> ;o5•L <br /> �___ WC -1NAIVErQ fly C-57 Letter of Authorization to sign permit V E=ncroachmenr doc 9/27/00 <br />