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ii <br /> r IT APPLICATION F M SITE <br /> W ELL'�r'ERM <br /> h SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CAt, 95202 UNIT IV <br /> (209) 468-3449 i xi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hefeby made to San Joaquin County for a permit to construct and/or install the work described. This application is made incompliance with <br /> San a uinQounty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Eivironmental Health Department• <br /> �� to� <br /> L LocaParcel# �' S Cross Streel ��s(o City " Zip /Assessors <br /> PROPE ,G� / f 7 <br /> Owner Address .�, [ ! lg�6 City /V Zipphone#6�C <br /> C-57 Contractor Address /[.e� fi City 51eTiTv Zip ���1ic#��•�phone k� /�v <br /> Consultant/Sub Cntr A d d r e s ' /y City C 'F Lic# Phone#}'70 <br /> GIS Coordinates:X Y <br /> Section Township Range <br /> i <br /> WORK TO BE PERFORMED, <br /> p NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') :E�STRTION (choose ty below) <br /> SOIL BORING# � -BORE.DIAMETERU WELL*Other , ? SURE GROUTSPECIFICATIONS Ij ICOMMENTS: re5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,t <br /> ISI []HOLLOW STEM DIA.OF BOREHOLE �]MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:2 <br /> �v <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS W { <br /> TYPE OF CASING: U STEEL XPVC a OTHER: <br /> 11 <br /> (]VAPOR U MUD ROTARY DEPTH OF GROUT SEAL Ifi TREMIE TYPE TO BE USED: U AUGERS <br /> OSE <br /> AIR SPARGE/OZONE []PUSH POINT(GP or GPT) ;II GROUT SEAL PUMPED: 'Yes 0 No <br /> NOTE: MAXIMUM FREE-FALL DEPTH IS 30') r� <br /> I]SOIL BORING U HAND AUGER GROUT SPECIFICATIONS ' <br /> I]OTHER: <br /> _UOTHER APPROX. BORING DEPTH <br /> U BOLTED TRAFFIC SOX or U STOVE PIPE <br /> section 0 (if YES, list specifications in comment <br /> CONDUCTOR CASING PROPOSED - <br /> COMMENTS: �J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. ! <br /> ! 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 Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company � <br /> DEPARTMENT USE ONLY _ Date.- <br /> II <br /> SITE MAP IN UNIT IV FILE,ADDRESS: SQ <br /> WORK PLAN DATED: <br /> ' 7( <br /> Application Accepted By Area <br /> Grout <br /> � � <br /> Grout Inspection By Date Issued S 6 <br /> Dale final Inspection By 0 •f ♦7ale <br /> Destruction lnspect on By Dale <br /> COMMENTS!CONDITIONS: I� <br /> ACCOUNTING ONLY: AID#, I <br /> FAC# I� I <br /> PIE CODES FEE INFO <br /> AMOUNTREMITTED C}fECK# <br /> REC'DBY DATE PERMITISERVICEREQUEST�t INVOIGE M <br />