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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> N. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s ov.or /ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <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 /> I Assessor's <br /> Well Location a��l r>�/W 4J� Cross Street �• V�aj� nv6,n City S6J\6-\ Zip iADV Parcel# <br /> Property Ij — <br /> Owner ort o-� Address 1q City f Zip Phone# <br /> C-57Contractor (ve AddressCity R (RLic#4gS -Phone562.62.q��( Tgl <br /> �tbl� SW Attu, 11) <br /> Consultant/Sub Cntr � C`� SStk.Address 06 City K",/QA'N I DR Lic# Phone 511'72.q L 6-q x 11 <br /> GIS Coordinates:X1 a v 26.0 3 k) Y (I A 512Q,VJ Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/BORING(CPT,GEOPROBHHYDROPUNCH.HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL ORING#_ ` ❑OVER-BORE DIAMETER <br /> WELLB <br /> ❑"OTHER — ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING aHOLLOW STEM DIA.OF BOREHOLE C ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: oZy <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 5v�A LW TYPE OF CASING:❑STEEL K PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS UHOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> OIL BORING HAND AUGER ( 1-er 1,r ) GROUT SPECIFICATIONS <br /> L]OTHER: MOTHER: J or��c��APPROX.BORING DEPTH7- to EPBOLTED TRAFFIC BOX OR ❑STOVE PIPE Qy <br /> CONDUCTOR CASING PROPOSEd (if YES,iist specifications in comment sections <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 A: <br /> al ap licable California Laws. (1y / 1 I p <br /> Signed (�> Title/Company Sr.. S1i C"F 6e.(yy-S /A,'l Cruz /ISSOL, <br /> Print Name _�t\N Date` 1 Z S/✓i <br /> L L <br /> C,`'/ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C 7/�_ / `A1 ��/ �`Q ilk <br /> WORK PLAN DATED: �✓✓Z•-�Q Q3 L�24e cl !/✓ p <br /> APPLICATION ACCEPTED BY DATE ISSUED ( __�AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY © DATE <br /> DESTRUCTION INSPECTION BY QDATE <br /> COMMENTSICONDITIONS: �fkAA V � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMIT/SERVICE# INVOICE <br /> cj'd 1 7,!p n q3 5- Nc 6f SR#4491- <br /> C 57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE 11T ENCROACHMENT DOC <br /> E HD 29-01 111/5/07(WEB) W ELL PERMIT APP <br />