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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN I SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ,. Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s o oreaW IV <br /> 1� I <br /> WELL PERMIT APPLICATION <br /> 2 2 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> UIR�� iT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appli t with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health D� EPUICEUS <br /> iCntr <br /> �� '�p�r Assessor's <br /> Well LocationCross Street ity Zip��� Parcel#PropertOwner A dress City Zip Phone# <br /> C-57 Contract �ddress CifV f�# Phone �ConsultanUSuAddress r J Clt�y <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NF­W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,<THE ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# T PRESSURE <br /> SPECT <br /> OTHER IICATIONS <br /> ❑ OUT <br /> COMMENTS:!/lhe/������ ��/ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE -S.— ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2L� <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS' TYPE OF CASING:ElSTEEL ePVC ElOTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT STREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑ PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes eNo ((NOTE:M IMUM F EE-FALL DEPTH I 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS - �G � /LI <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> SB� n DTOR CASINGpRpPO$,E�DQ� f YES,list specifications in comment section) <br /> COMMENTS: C <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 applicable California L ws. / <br /> Signed Title/Company <br /> Print Name Date J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ✓��Q Lt� C/_�. <br /> APPLICATION ACCEPTED BY ',�l DATE ISSUED /ZL AREA <br /> GROUT INSPECTION BY "�` '� FINAL INSPECTION BY DATE? �5 <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 /> O �5— X72? 14-<< Z 0 SR#005-73x1 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115/07(WEB) WELL PERMIT APP <br />