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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 County Environmental Health Department <br /> `+ Assessors <br /> WELL Location ( W, �l0VMi� f4Ve Cross Street I~1 r--Val 1Qutity/tai,/t(eccZ Z,p9s33� Parcel# Z14`030—t�3 <br /> PROPERTY Owner-I-lev-ea' -1*'e­ _Address �`O' r3t"C -7[t City t)Cf 'PX Zip 7S`2-z] Phone# <br /> C-57 ContractorydeWD� illrn�� —Address &3)( �Ib City �`1 ZipqS6L[IL�c#?2fl`�CIPhone# �iI6 7-7 7-k1]- <br /> j-gr.Cho oL4pO <br /> Consultant/Sub Cntr S E GoR- -:P- nQ�ia�,IAddress 3�l'7 K~1 U e �a City Cu C Photic# Phone# Q(6 S'bt- <br /> 5r kUx) �l <br /> GIS Coordinates X y Its <br /> —- Range Section <br /> WORK TO BE PERFORMED <br /> (]NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) VESOTR R BORON DIAMETER pe below) <br /> []SOIL BORING# <br /> []WELL# ;PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> [] EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL []PVC []OTHER <br /> aRPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED []AUGERS []HOSE <br /> SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED []Yes []No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING [}HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER []OTHER APPROX BORING DEPTH []BOLTED TRAFFIC BOX or H 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 /> 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 /> Signed x <br /> Title/Company <br /> prQl�G} Gealo4 <br /> Print Name zr t C'A f- q Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued f v J <br /> 7 <br /> lf <br /> Application Accepted By Area <br /> Date Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> CCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> eZ � f Z3 p SR# p®3 �7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit,X Encroachment doc 9/30/02 <br />