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FILE COPY <br /> *., HEALTH <br /> ED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 10 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468.3433 Web:www siaov.orglehd UNIT IV <br /> E PENMERVICES 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 <br /> nnDevelopment Title.chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location l'a Yd V 5,L&C Cross Street B iry \I(CALr14 _ZIP Parcel i& A22-D <br /> Properly Cl-v-o sSt-oad.S 4P-lL0 Zig Phone#�� <br /> Owner;.#.�n. ,c 1..E-0-cIT Address" �b `C`'V'DL� 0.f+ �N Ciry�� � ,L�� �� D1V <br /> C-57 Contractor(OY� Address q5Z Lici 1 6� Phone <br /> ConsuRanVSub Cntr tp. <br /> �j' . Address IC4L1Ll'Cl 12tt)p}(�,]T % City ' OG MC)TYICL Lic# Phone-41RA j 2;Mvy N <br /> %-7 <br /> GIS Coordinates:X 3-7.7-0W ,Y "VrS)o ,Township Range Section C <br /> WORK TO BE PERFORMED: <br /> NEW WFLUBON!NO(CPT,GEOPROBE,HYDROPUNCH,HAN0.AUGER`OTHEP•• I oESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# l'-GP'C� .1❑OVER-BORE DIAMETER <br /> t1 ❑WELL#, VYL1L+rs �, /0 PRESSURE GROUT <br /> 0*OTHER <br /> -r�� GROUT SPECIFICATIONS �An <br /> COMMENTS: <br /> MTYPE OF WELL v INSTALLATION TYPE CON`TRU ON SPECIFICATIONS <br /> YN MONITORING ((( HOLLOW STEM DIA O OREHOLE If Cl MULTIPLE CASINGS 0 MULT4LEVEL WELL CASING DIA:L I/ <br /> ❑EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS 5411, NO TYPE OF CASING:O STEEL PPVC 0 OTHER <br /> tI <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�2- TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE j1Lk'_,'j <br /> e. <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CP'f)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING O HAND AUGER GROUT SPECIFICATIONSITT <br /> 0 OTHER: Cl OTHER: APPROX.BORING DEPTH ~ 40 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONQ1CTORCASINGPROP:bE13 Itt YES,Ibl spetlrollomfWmmreld realm) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACyMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 /> Regulatlona,and all applicable Call mla L .0 _ <br /> Signed �+ Tale/Conlpam l' A1^ L� SOC 4 VC/ t9 ( LOh so-f- <br /> PrintName U y 1'1 l IL 1vt� � Date LL )'C) <br /> Cr DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ L <br /> WORK PLAN DATED: 0q �y nL,�((// <br /> APPLICATION ACCEPTED BY DATE ISSUED 3 Z Z J ARFAO <br /> GROUT INSPECTION BY 2OID FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> LACCOUNITING ONLY: AID# FAC III <br /> DES FEE INFO AMT REMITTED CHECKS RECV'D BY DATE PEIRMITISERVICE# INVOICE <br /> 11 �i. 2oZ_9p IL-II-a4 0}r5� <br /> C-57 V WC V, -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT If ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> eHDaael 11/ ("EBI <br />