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---- <br /> curl <br /> fAw."K Iv1 WELL PERMIT APPLICATION FLjRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV 1 t <br /> AUG 10 94 E. Weber, Third Floor, Stockton, CA., 95202 3 �� <br /> ENVIRONMENT HEALTH (209) 468-3449 DAJ . <br /> PERMIT/SERVICE6-REFUNDABLEPERMIT EXPIRES 4 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 /> Q` Assessor's <br /> WELL Location LID �• r Cross Street r Ci Zip 172'1 Parcel# -���} r'2- <br /> PROPERTY Ownei /7�s4G Address JA 11ra- a y City/,W. N-j- Azid076,75Phone# <br /> 20 Cit uc aZip V L1c#&NI614 Phone# a� 1 <br /> C-57 Conlracto 1r _ r� A�d�drres(s i f�� �y <br /> Consultant Sub Cntr�FftW'fjOLe&4&(?tit'NVWWAddress i7� QM i Lic#!l ii�JD Phone ( - 1 to <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•} p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ELL# - d PRESSURE GROUT <br /> 'Other: !" Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �{ <br /> Y120 <br /> NITORING �OLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?0 MULTI-L-EVEL?0 WELL CASING DIA:�1D <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS O T�(PE OF CASING: 0 STEEL VC p OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL_ jTREMIE TYPE TO BE USED: UGERS �D$E <br /> 0 AIR SPARGE I Ozone 0 PUSH POINT GROUT SEAL PUMPED: xes 0 Na (NOTE: MAXIMUM FREE- ALL DEPTH I, ') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH f LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? tL) _(if YES,fist specifications here): <br /> 'COMMENTS; <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 Ordi Rules and Regulations,and all applicable California State Laws. <br /> Signed x C2 Title/Gompany <br /> 11&kAVlal{iwww <br /> Print Name 530 Date 5 <br /> DEPARTMENT USE ONLY r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Area 196 <br /> Application AcceptedAABy Date Issued � � � 0 � <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 N�v11 O t053if S 10 403q 3z5 02 I' <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc B/29/ <br />