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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Coun nvironmental Health Department. <br /> Assessorsnn CC <br /> �� �ei Zi `9� 3 arcel# y/ l! D�& <br /> WELL Location Cross Street City P <br /> i s <br /> PROPERTY Owner G1 S� /'� Address City fgtC <br /> �blo/ G 2�.e ZIP FiTr v Phone# <br /> �✓ v.+G. Address <br /> C-57 Contractor r77o 5 <br /> Ci ip9 ic#Phone# 2l6�� <br /> Consultant/Sub Cntr r19�i�-4 99VV Address �l �Ity -clr Lic# Phone# <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WO K TO BE PERFORMED: <br /> K WELL/ BORING/ (CPT EOPROB ,HYDROPUNCH,HAND AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING#( 0 OVER-BORE. DIAMETER <br /> ELL# - n PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> 0'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONNITORING IOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: Zu <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 'fl2yYPE OF CASING: 0 STEEL 2 a T ,W/C 0 OTHER: <br /> G VAPOR H MUD ROTARY DEPTH OF GROUT SEAL���- fRyEMIE TYPE TO BE USED: 'j Q J�GERS []HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: �s 0 No VOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH �LOicj�5f• OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Regulations, and all applicable California State Laws. <br /> Signed x -'r <br /> Y17 <br /> Print Name r� Date <br /> ?UIT <br /> DEPARTMENT USE ONLY <br /> SITE MAPIN LE, ADDRESS: <br /> WORK PLAN DATED/: E'S*4 <br /> Application Accepted By (� amt& Date Issued O( s� D� Areae"( <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> of $7 39 7133 144 =2-ct sR# o�3 �3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br />