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curl <br /> WELL PERMIT APPLICATION FvRM SITE <br /> MRECE�NEID <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> HEALTH DEPARTMENT (EHD) <br /> AUG 10 2xTVIRONMENTAL <br /> 4 E, Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES 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.Assessor's <br /> VVELL Location fa- 4e, !u Wwgy[ • Cross street pity t k Zip Parcel# Qq- -030~13 <br /> PROPERTY Owner e &Q( ddressy *L050 'cit4 ��-Zipq0Lf0 Phone# Ixo- <br /> C-57 Contractor u� ��' Address (aI � � Ci /� Zipis Lic# �j1Phone# <br /> Consultant I Sub Cntr (Address5 y� Cih+�Lic#Q�i 30�' Phone# �. <br /> vlf�w <br /> GIS Coordinates:X <br /> Y,,Township ` Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0jW.EW WELL/BORING(C PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) OVER-BORE <br /> Q SOIL BORING# PRESSURE.GROUT <br /> �1lELL# <br /> *Other._ Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n u <br /> 4)B3-1 <br /> ONITORING OLLOW STEM DiA.OF BOREHOLE 4A�MULTIPLE CASINGS?0 MULTI-AVE?p WELL CASING DIA: <br /> D EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS�i _TYPE OF CASING: 0 STEEL IC 0 OTHER: <br /> SEAL Cyt �_TREMIE TYPE TO BE USED: pQUGERS ?obi SE <br /> 0 VAPOR D MUD ROTARY - DEPTH OF GROUT <br /> 0 AIR SPARGE/ozone 0 PUSH POINT GROUT SEAL PUMPED: gDes 0 No (NOTE: NJAX[MUM FREE-FALL DEPTH IS 30 <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: -1 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (if YES,list 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 Ord' estRules d Regulations,and all applicable California State taws. r <br /> Signed x Title/Company <br /> �. Date a <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: fZ/U , <br /> WORK PLAN DATED: /o �3 <br /> iF <br /> Application Accepted By <br /> Date Issued ! ~ ?/ Area <br /> Grout inspection By <br /> Date_ Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 00 3R`f <br /> En <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign per Ment 8/29/0 <br /> � <br />