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�r2@SZ 15:22 2094683433 FIFTH FLOOR <br /> PAGE 02 <br /> Ems' <br /> WELL PERMIT APPLICATION! FUR" M <br /> SITE <br /> i <br /> SAN JOAQLIIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EMD) UNIT'iV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON-REFUNDABLE PERMIT EX IBES 7 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 Developme6t Title,Chaptgr 9-1115,3 and the Standards of Sart Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location :c r Cross Street'lc1 Assessor's <br /> ��x.r p !� City 51, �f n Zl S�o' Parz el#r9 � O� E7 j <br /> 5'ys fc.n /,Of/ll �9 City.X17 Curr ? <br /> PROPERTY Owner C-4 o 4•;a n W,Tr!.>x,�.,.. �OfA �ass � , <br /> r C45� 1,1 I1'u6rnn Zip Phone#���5`��`ttuf� 1 <br /> C-57 Contractor <br /> Address 3 Oft cc C r c L CiIYK ,v tr zlP± 7`f d LIc#?17 5-70Phoae# (, - 3�-11E,nr <br /> Consultant/Sub Contractor S CAddress' f0O <br /> City 4v.do �s Lfo# Phone#`�16 $6�d fj <br /> GIS 0wrdinates:X Y Township Range Section f/ <br /> WORK TO BE PERFO MEb, <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,}LAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> I7 WFu� .OVER=SORE <br /> VRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: ry a p„r <br /> TYPE OF WELL INSTALLATION TYPE CON$TR!&TIQN SPECIFICATIONS <br /> ZgMONITORING 11 HOLLOW STEM DIA,OF BOREHOLE_ MULTIPLE CASINGS?13 YES ;ONO WELL CASING DIA: r� <br /> a EXTRACTION 0 AIR HAMMERJORIVEN CASING THICKNESS ;Ch o ' TYPE OF CASING: [1 STEEL ja FVC [1 OTHER: <br /> Q VAPOR" 0 MUD ROTARY DEPTH OF GROUT SEAL -1Y p! TREMIE TYPE TO BE USED: 13 AUGERS 0 HOSE <br /> 0 AJIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: J Yes p No (NOTE. MAXIM U M FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:� ee-r-e 17-{ <br /> U OTHER: ft OTHER APPROX.BORING DEPTH 6p '[)BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? fl-"v [if YES,list specifications here)- <br /> -COMMENTS.- MLA.— <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San,Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws- <br /> Signed ySSGp/+s <br /> Signedx TltlelCam an ' r� �e f- 5crsrr4 h <br /> Print Name c /;/1 r s DSW ' 47 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued L l,2 Area <br /> Grout InspeCtlori By Date Final InspetGon By Date <br /> Destruction Inspectlan By ft U Date �$ 0 r� <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK V REC"D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-5? WGI� <br /> -WAIVF ,_ C-57 Letter of Authorization to sign�pern,it_k Encroachment doc 9!27/00 <br />