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SAN JOAQUIN COUNTY <br /> !`�jDENftONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> \�. P Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sigov.orq/ehd UNIT IV <br /> roPR 2 2 2008 <br /> WELL PERMIT APPLICATION <br /> ENVIRONMENT HEALTH <br /> PERMMSEPVICES 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 /> Assessor's <br /> Well Location NeAk Cross Street F STS f City 6APT-A Zip -1(�53-36�1 Parcel# 2-5b010Z3 <br /> Property Un,•n Aar.f f?w;l road C d. y y/� �?id'ie -, g"b-v 0,30 61"79 <br /> Owner a '- ddre-s City b&o"- Zip c 51 3310 Phone# &J-835-2150 <br /> s <br /> �4s•53o ur4 <br /> C 57 Contractor KS! D�t t L t tJt, Address ?-20 1J FJ1ST J6T City w CIO 9LR N7 ZipL c# SS02 3 Phone <br /> Consultant/Sub Cntr CPN4IKOtP[Nr lr;[. Address h244 KttPS In>A11 City 6o%z c ocis, Lic# 1a(11 Phone 9l(. A51.013 ► <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> tkNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑OVER-BORE DIAMETER <br /> &WELL# NLW- PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Ir <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE _& ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS"N 40 TYPE OF CASING:❑STEEL IQPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED,(AUGERS❑HOSE <br /> ❑AIR 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 Fe 1"ll WALLNT <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH t <br /> [:1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulationl a p'cable California Laws. <br /> Signed Title/Company &P-)( VI(c-z'—ie& N <br /> Print Name 0"I5Ttl P,)LA[k- Date I,D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �/ <br /> APPLICATION ACCEPTED BY l(4�'<� .: trio j / ATE ISSUED S Zg -0j- AREA IVr3 <br /> GROUT INSPECTION BY lF AL IN Pr ON BY DATE <br /> t <br /> DESTRUCTION INSPECTION BY TE <br /> COMMENTS/CONDITIONS: ri <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> 36 <br /> oe X294 x`383 °U 36i79 f, 362579 ejV7,? � 2z `say SR# oo5'13 76 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT/ ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />