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SAN JOAQUIN COUNTY h <br /> ���0�/J <br /> N �< ENVIRONMENTAL HEALTH DEPARTMENT fill SITE <br /> 600 East Main Street, Stockton, CA 95202-3029APR 2 <br /> q L,fit,� P 32010 MITIGATION N <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web: s ov.or /e UNIT IV E <br /> HEA <br /> WELL PERMIT APPLICATION PERMIT/SERME3 <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 County vironmental Health Department. <br /> City <br /> p 9 Assessol's�C� <br /> Well Location Cross Street e-- Ci (! �l Zi �� Parcel# <br /> Property II � -tb <br /> Owner O Address 000 ECAi C <br /> �lr n Zip 97 X6 3 Phone y13(f�0 <br /> 5 <br /> C-57Contractor �Upryb Addresd City&OVJU Lic3�Phone�507-201 <br /> Consultant/Sub Cntraa_ Addresso .o� Rn- 'r d4 City . � Lic# Phone)0 -7 - <br /> 13 / <br /> 3a.�_ `l nq <br /> GIS Coordinates:X Y -�o7I. 2/�3 Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT GEO ROB HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORI G# ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT -I-rL°w4ttAtt <br /> 'OTHER 1 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l r <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE1 dam. EI MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: <br /> El EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS l t t TYPE OF CASING:❑STEE4PVC ❑ OTHER <br /> 2 <br /> ❑VAPOR `1❑MUD ROTARY DEPTH OF GROUT SEAL� J TREMIE TYPE TO BE USED El AUGERS❑HOSE <br /> [I AIR SPARGE/OZONE L1SH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yesj�-Wo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> El SOIL BORING /❑HAND AUGER GROUT SPECIFICATIONS 1 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH OLTED 1f1'BOX OR ❑STOVE PIPE <br /> -y— I� CONDUCTOR CASING PROPOSED ('rf YES,list specifications in comment section) <br /> COMMENTS: I •QtdAll 4M �-- A['�t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify t I have prep red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all ap licabl California Laws. <br /> Signed cJ A, Title/Company /U � <br /> Print Name / Date 2 <br /> DEPARTMENT USE ONLY p ` <br /> SITE MAP IN UNIT IV FILE,ADDRE S: Q�fZ <br /> WORK PLAN DATED: Z D /lam- <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE ►►,, II -� <br /> COMMENTS/CONDITION W o-a <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> -OTO-L— �cl Z b �� t o SR#dd 1��3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />