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WELL PERMIT APPLICATION FORM SITE <br /> ; — L <br /> MITIGATION <br /> :iLSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESj ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT N <br /> NOV 2 9 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ._I4T HEALTH <br /> (209) 468-3449 <br /> F i,, �glll Cs <br /> PE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instait the work described. This application is made in compliance with San <br /> Joaquin County Development Titie.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,l=Wronmental Health Division. <br /> Assessors ` <br /> WE=L Location 7 &6 EIA''Str Cross Stre1V— r 1 City Zip Psrrel#��` $ fl i <br /> PROPERTY Owner i ��'Grt W ✓- Address 3U/V- G�?UKd1C9ty r' ZtpPhonefl <br /> C-67 Cantracier Ar��a+�c e r [en u �}_ Address 4a 3s1�cu.� (�J. aty���Mpl�L u� 6��honef 20 �// <br /> Consultant!Sub Contractor/b)cU G Cxp V Address $37 4 f�u? , _CIty�C.62 Lic#—( <br /> hon #a�✓r b7 `U <br /> GIS Coordinates:X Y Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPLICH HAND-AUGER,OTHW) []DESTRUCTION(choose type below) <br /> XSCIL BORING# Lor« to rt,f (}OVER-SORE . <br /> a WELL# p PRESSURE GROUT <br /> -Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING []HOLLOW STEM DIA.OF BOREHOLE Q' —MULTIPLE CASINGS?[I YES a NO WELL CASING <br /> gEXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS / 7 TYPE OF CASING: D STEEL U PVC n OTHER <br /> a VAPOR []MUD ROTARY DEATH OF GROUT SEAL__E 0-� (Ve TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> Q AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: q Yes 114o (NOTE: MAXI UM FREE-PALL DEPTH IS 30') <br /> SOIL BORING *AND AUGER GROUT SPECIFICATIONS: 0&r!1 b S�� _ p 6- &0 UM <br /> []OTHER [I OTHER APPROX BORING DEPTH I C (I BOLTED TRAFFIC 86X or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (it YES,list specifications here}: <br /> 'COMMEWS, <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, Rules and Regulations, and all applicable California State (Laws. <br /> ` <br /> Signed x Tille/Company 5:6 <br /> Print Name r I cf h j0 It(M&O D a d' <br /> DEPARTMENT IUSE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I ry-\, O JJ <br /> WORK PLAN DATED: 12&x -e v)Lov <br /> Application Accepted Byyy Date issued 3 Area <br /> Grout Inspection By t1'C^ O'IiC�t) _Date G Final inspection By_ Date <br /> Destruction Inspection By U Date; <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D 8Y DATE PERMIT I SERVICE REQUIEST#. INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />