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� rl <br /> WELL PERMIT APPL' ICATION FORM, SITE k <br /> ,I MITIGATION <br /> �} } I ,I�/ `�_ SAN`JOAQUIN COUNTY <br /> L— `amu ENVIRONMENTAL HEALTH DEPARTMENT (P-HD) UNITiV <br /> S 2007el$$E. Vober,Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> T P1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED <br /> Appllcahoo����ss qrJf�d�`1,�� oaquin County for a perm)!to caristruct and/or install the work described. This application is made in compliance with San <br /> Joaquin G`o'unr'pevdlopment Title,Chapter 9-1115.3 a d the Standards of San Joaquin County Environmental Health Department. <br /> I _]7�� - P Assessor's g <br /> WELL tocation 5 �\T(r - ssSlreet City '�oo�c�C�cf .zip. Parcel# r� 7'2�C� <br /> PROPERTYOwner� J Address ,0..'!� City d� - , Zip9�i Phone# ZQGl . 46261 <br /> ?� rs z y r oz <br /> C-57Contractor a� �fl Address CityZip_-9��6Licq s Phone#17/6'-`11/-02, 3 - <br /> Consultant lSub Contractor Address' Ctry Llc# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO 81;-PERFORMED: <br /> a NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,'HAND-AUGER,OTHER-) XOESTRUCTION(choose type below) <br /> E aBOIL BORING# r 0 OVERBORE <br /> ,PRESSURE GROUT <br /> 'Other: ' Grout Speclficalions: <br /> i COMMENTS: Ill iU 2 diiAX 1115 lul _ ' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING PIA: <br /> 0 EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC []OTHER: { <br /> 0 VAPOR U MUD ROTARY DEPTROF GROUT SEAL TREMIE TYPE TO BE USED. p AUGERS p HOSE ! <br /> 0 AIR SPARGE D PUSH POINT GROUT SEACPUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS; <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or ,, JTOVE PIPE <br /> CONDUCTOR CASING PROPD3FD? .(if Y5V rict 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 appEfaation and that the work will be done in accordance with San Joaquili <br /> County Ordinances, Rules and Regulations,and.all applicable California State Laws. <br /> I <br /> Signed x_... Title/Company—C-4- <br /> Print <br /> illelCompany Print Name DEPARTMENT USE ONLY- DatecT4d'7 <br /> SITE MAP IN UNIT IV FILL,ADDRESS: <br /> F WORK PLAN DATED: u7Q. ZOe7 _ r <br /> Application Accepted By Date Issued lCJ D7 Area !' <br /> I Grout Inspection By_ Date 401" <br /> 0 1"-9 07 Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: O <br /> ACCOUNTING ONLY: AID# <br /> CArf! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#i REC'D BY DATE PERMIT/SERVICE REQUEST#> INVOICE <br /> t�z 60– (mob' <br /> s <br /> C-57 WC.---WAIVER- C-57 Letter of Authorization to sign permit Encroachment doc— : 1/25/02 <br /> 5 0� <br /> sly 0-ri Y Sit a /. g/r61d� <br /> I <br /> I <br /> t , <br />