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!9b/lt3/ZUU-4 lb:OU LU 0 314.3.3 r Lr in r L-u r , <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppGgtipn 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. p 1-111and the Standards of San Joaquin County Environmental Health Department, <br /> ALL Location rosy Street C'ty Soe <br /> pParcel# <br /> PROPERTY Owner Q Address �! City Zips,&Phon )DQ-014 <br /> s <br /> c-67Contractor2S/1 K�aJGx tom.)t_Li�ddress a O A A t ��citySn�d l r,�,r�¢.�i }licAs�nE '0)5(23 <br /> Cort6tlttant/Sub Chir e 2 1��h Address NCS AJ J.Oo3 City ucl/.�Phpne# O .2 a7 <br /> 7 <br /> GIS Coordinates:X N ,Y ,Township T I Range&'s.C% Section ✓ <br /> WO S TO BE PgRFORMED: <br /> EW WELL/BORING(CPT, EOPR HYDROPUNCH,HAND-AUGER,OTHER*) ESTRUCTION(choose Lyrae t,elav) <br /> a WELL# G# i�E�?/� I]OVER-BORE <br /> Grout Specifications:cations. PRESSURE GROUT <br /> COMMENTS U ,--t�-,t /"-ixg 1-10U/<� �(L' CZV <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA'nONS <br /> TgbNITORING Q HOLLOW STEM DIA OF BOREHOLE r� MULTIPLE CASINGS?[]MULTI-LEVEL? ,WELL CASING DIA <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING= II STEEL PVC Q OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT S TREMIE TYPE TO BE USED: Q AUGERS Q HO FV,17 <br /> ]AIR SPARGE/Ozone Q PUSH POINT GROUT SEAL PUMPED: p Yes, Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS. <br /> ]OTHER: n OTHER�'4�- APPROX.BORING DEPTH--/Q/'�,-131-7 <br /> �Q BOLTED TRAFFIC BOX or jJ S70VE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> ;T� _(if YES,Inst specifications here): <br /> f-aV G�7'Tx�- <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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> :Ounty 'nances, Rules and Regula i//on``s,and all applicable California State f y 1clam <br /> signed x W S W Tiae/Company - �� Qt11lu' 15I <br /> 'Mt Name ALrLData <br /> DEPARTMENT USE Y OENNISP. N <br /> OVYSKI <br /> � <br /> ;ITE MAP IN UNIT IV FILE,ADDRESS: MASLONKLONKgg <br /> YORK PLAN DATED: r ,, <br /> PPTication Accepted By <br /> —A=q� Date Issu %Are <br /> ;rnut Inspection By Date Final Inspec5on By Date 61 <br /> estruction Inspection By Date ' <br /> OMMENTS/COMMONS: � /. <br /> ACCOUNTING ONLY: AID# <br /> Garr <br /> PE CODES FI`E INFO AMOUNT REMITTED CHECK# RE 'D BY b PERMIT/SERVICE REQ1JEST p INVOICE <br /> z �l .� PR* I <br /> :-57 WC -WAIVER C-57 Letter of, t It Encroachment doc 8/29/02 <br />