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`eon • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> �❑ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> \ P GV e:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.orD/ehd UNIT IV <br /> NOV 13 Z009 WELL PERMIT APPLICATION <br /> ENVIRONMENT HE"iREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is erPj+yQM��($%u®County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County e l spier 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> sc <br /> Asses <br /> iWellLocation Cross Street city e u ba- <br /> Property cAo-of <br /> Owner C . ll,�'�7 Address 'at-l% 1Sc city Zip Phone# <br /> C-57Contractor Address 3 city NYo4LUt IlcNcg AFD#6538 $Phone <br /> Consuhant/Sub CntrAddress City SS&\CpVn Lic# -1 x4 Phone <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT, OPROB HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ]-SOIL BORING# ❑OVER-BORE DIAMETER <br /> [3-WELL# RPRESSURE 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 HAMMERIDRIVEN CASING THICKNESS Ur�' TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL /-'ZI ITREMIE TYPE TO BE USEDD AUGERS HOSE <br /> aaaa� <br /> ❑AIR SPARGE/OZONE APUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes EbNo (�N7OTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS I )Ef}T- C En4,S \/ I <br /> 1 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH —2-1 ❑BOLTED TRAFFIC BOX OR ❑STOVE <br /> &W. <br /> CASING PROPOSED (if YES,list"ciR Wns In cammmt"s an) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 8a <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS MIC <br /> I hereby Certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regula s,and all Ilcable California Laws. <br /> \— <br /> s—SigneddTitslCompany <br /> Print \ `I <br /> Name `1`��\���N� Date \\- \\ q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVCHLE,ADDRESS: 130 15 Fwy4 S-f N}e ja( �r2009 <br /> WORK PLAN DATED: g 'L 6 S' 2FS <br /> APPLICATION ACCEPTED BY t1tjjNy1GCA� DATE ISSUED II O /M _ <br /> GROUT INSPECTION BY Id FINAL INSPECTION BY tA_ � ^� o_� DATE 2 3/07 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 1 S <br /> t ( 0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> Z`1�5 y3qIoo 1-61 :75 U ilIfi c SR# SS-4f56 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 2"I 11/SID?(WEB) WELL PERMIT APP <br />