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. . SAN JOAQUIN COUNTY <br /> ENVIt , JNMENTAL HEALTH DEPARTME. . . C,E�1,V t LAITE <br /> i 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209) 468-3433 Web:www.sigov.o2 ZOOS UNIT IV <br /> WELL PERMIT APPLICATION ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <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 /> Assessor' v <br /> Well Location Cross Street City zip # �! <br /> Property fy-�9//n T X�Phone#�Q- ��z��S <br /> Owner Addres 4��r4��' ' -,� - City P <br /> r r t p <br /> C-57 Contractor C ( ' adres City c#V�Phone <br /> Consultant/SubCntr Address rz�City Lic# Phone - ` <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ZVLW_WELI_/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER. THE ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ❑ WELL# ❑ PRESSURE GROUT <br /> ❑ `OTHER GROUT SPECIFICATIONS <br /> C0MMENTS:_4&e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r <br /> XMONITORING ; HOLLOW STEM DIA.OF BOREHOLE 10— ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL Z_PVC ❑ OTHER <br /> ❑VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL A 5 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑ PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXI AUM FREE-FALL <br /> /DEPTH I 30')) <br /> ❑SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS�,����T <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH ; oOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CABG FO,SEEDD (it 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all app li able California La s. l <br /> Si nedzn� Title/Company r ( , <br /> 9 <br /> Print Name Date) <br /> ? <br /> DEPARTMENT USE ONLY A <br /> SITE MAP IN UNIT IV FILE.ADDRESS: >� Lcc_ <br /> WORK PLAN DATED: w IGI�/� <br /> APPLICATION ACCEPTED BY DATE ISSUED�Z� 0 AREA <br /> If <br /> GROUT INSPECTION BY ( FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> X9.0/ F5 e�_ /?,? I'VIeG � ,05 SR#DOS? 30-3 <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 />