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lU/L'1/2UU/ MON 1314.5 FAX 20946U3)' ' SJC.`EH6' <br /> 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> �i -ri;,;lili 'SAN JOAQUIN COUNTY <br /> MITIGATION <br /> 1Y <br /> ENVIRONMENTAL! DEPARTMENT(EHD) UNIT IV <br /> `E. V ber;`ThirdEFloor,Stockton, CA., 95202 -"-. --- <br /> .(260 4683449 <br /> I\yViiA. IJaN.itEF)NdA8'LE PERMITE7(PIRES 1 YEAR FROM DATE ISSUED <br /> APPI1611 � hgrfp�yyf�de t�IUbsoaquln County for a periell'lo conslnicl andfor Install the work described, This appllcanon is made in eompllance with San <br /> Joaquin=4 Dr v6lopment Title,Chaplet 9.111513 a d Uig Standards Of San Joaquin County Environmental Health Department. 'I I <br /> I �+ / 11! Assessor's I <br /> WELL Locallon .� � !?t�T 1. Rin} 4I�rass Street''I ,c City ,cQ- c zip Paf6elfl ��^72 <br /> ,a is <br /> PROPERTY Ownert��"J�f�.f•./� Addressr '� I City r. 2Ip� ��� Phone# <br /> ,r r <br /> c-57 Contractor- l�.L.l (�r�/J Address-sS ls.�_Et1�C�L ,,tt�h_City n�nr � � �Icft rnC.Phone# 714 <br /> Consultant 1 Sub Contractor <br /> Address Cfty Llc# Phone# <br /> 'ta <br /> 016 Coordlnales:X Y Tovinshlp Range Secllon <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/SORING(CPT,GEOPROBE,HYDROPUNCH,-HAND-AUGER,OTHER`) XOESTRUCTION{choose type below) <br /> 0 SOIL BORING# Q OVER-OGRE <br /> p WELL 9 - P _ .. -;PRESSURE GROUT,_ <br /> •Other: Grout$ eancauons: <br /> COMMENTS: �7Yl yf Z �i � <br /> t.: : . tI <br /> TYPE OF WFLL 1t r1,-SMLLATIONTYPE CONSTRUCTION SPECIFICATIONS i <br /> (]MONITORING a HOLLOW STEM l7lA OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DtA: <br /> 11 EXTRACTION 11 AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING; OSTEEL 0 PVC` Q O7tiER: I <br /> U VAPOR 0 MUD ROTARY DEPIH OF GROUT SEAL TREMIE TYPE TO BE USED: q AUGERS 11 HOSE !! <br /> ,.; <br /> 0 AIR SPARGE 0 PUSH POINT GROUT'SEAL PUMPED; 0 Yes 0 No ,NOTE:MAXIMUM FREE-FALL DEPTH IS 34') <br /> 0 SAIL BORING II HAND AUGER GROUT SPEC floATIONS, <br /> -� <br /> 0 OTHER 0 OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or <br /> t, STOVE PIPE <br /> CONDUCTOR CASING PROPD$FD'' r if Ycc rite specifications herd'):_ <br /> `COMMENTS_,_- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING:HOURS 1N ADVANCE FOR ALL REQUIRED INSI ECTIONS,• <br /> I hereby certify that I have prepared this appliaatior, 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 /> r� f <br /> Signed x "� � TittelCampany � � �Cg--�rrL�. E•-'��� <br /> Pr;nl Name 'II ----—pate-(r ,'Zo Q <br /> DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATgD: u TOOT <br /> Application Accepted By_ iu bate Issued !C1 07 .i Area <br /> Grout Inspection 5 Date ID l,, D final Inspection By <br /> Dealruclian Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> /f ACCOUNTING ONLY; AID# <br /> xnre <br /> PE CODES FEE INFO AMOUNT REMITTED CHPCK# REC'D BY PATE PERMIT IS ERVICE REQUEST# INVOICE <br /> r Cab S.y�o- ' (AK I ry o SRR <br /> C-57-____, WC_-WAIVI_R^ C-57 Letter of Author;izotion to sign permit____.Encroachment doc_t 1/25/02' ; <br /> } <br />