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C, nn <br /> WELL PERMIT APPLICATION FvRM D <br /> SITE <br /> RECEff ED SAN JOAQUIN COUNTY MITIGATION <br /> IRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> AUG 10 2C E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICESNON. EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sarf Joaquin County for a permit to construct and/or Install the work described. This application Is made in,compl�ance with San <br /> Joaquin County Development Title,Chapter 9-11153 and the Standards of San Joaquin County Environmental Health Deparlment•Assessor s <br /> WELL.Locatlon (4 E QIr1�l�t.• Cross Street 2e4yecity S�G� Zip Parcel# <br /> PROPERTY Owner !y, rPro KCAddress � l�'�1 ID C+ �i�1�Phone# O -g 71 <br /> C-57Contractor • &�elll r G d- Address Ci Zip gb pOpLi�aPhone# - <br /> Consultant/Sub Cnt_t6 *oh#7t1+�1 -% Address IWT [ ity Lic#tW Phone# <br /> e ` s <br /> GIS Coordinates:X ,Y Township Range Section <br /> WO'RKTO BE PERFORMED: DESTRUCTION (choose type be)ov <br /> �EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 13 OVER-BORE <br /> r 0 SOIL BORING# 0 PRFSSURE GROUT <br /> )MELL# <br /> 'other. 111171 Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (� lit <br /> ONITORING LLOW STEM DIA.OF BOREHOLES"MULTIPLE CASING�S7 0 MULTI-LOL?0 WELL CASING DIA:, <br /> d EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL C p OTHER: <br /> ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE SED: UGERS41OSE <br /> VAPOR Q MUD <br /> p AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: @Yes p No (NOTE: M IMUM FREE- ALL DEP7 `_rsj 30 <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> t1 OTHER:_0 OTHER APPROX, BORING DEPTH <br /> i PLTED TRAFFIC BOX or Q STOVE PIPE <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 Ordin Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Jot <br /> Print Name <br /> e ` 5 � Date b <br /> T. DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A=4� <br /> WORK PLAN DATED: o3 _ / <br /> Application Accepted By <br /> Date Issued Area A 16 <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destrudlon inspection By Date <br /> COMMENTS l CONDITIONS: <br /> MC-57— <br /> ONLY: AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C -WAIVER C-57 Letter of Authorization to sign permit^Encro meet do� <br /> 8/29/( <br />