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o San Joaquin County <br /> H <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chit <br /> Well Permit Application UNIT 11/ <br /> NON-RGFUNDA61-6 PERMIT EXPIRES 1 YEAR FROM DATC ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work d080rrbed. This applioation 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, <br /> WELL.Location Z �LYt /- �? �1 �l 2 160 0$ <br /> ort Cross Straot {c Cit Aarce YE <br /> l r�L� y Tr— —ZIpl�PL ce;7�_ <br /> PROPE �A <br /> Uwner �orTFCirtSr3•r-f= Adaress3 <br /> C-67CAddress � a / N dary C;CL <br /> ConsultantI Sub Cntr1A-l}rJLQDdLLR1ZZIi717Penll <br /> sies dnex <br /> Phonhee#n <br /> e#�%�. <br /> Lid# •,� ,gzOU <br /> GIS Coordinates-X ,V , <br /> WORK i0 BE PERFORMED, Townshi <br /> P Range Section <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER• DESTRUCTION (choose ' <br /> DWELEO N # FIt E COP1 type below) <br /> a WELL# ,2C, ( DOVER SORE. DIAMETER <br /> — <br /> a r GROUT COMMENTS: <br /> TYPE OF WELL INSTALLATIOK:1YPE CO.NSTRLLCTION Sp CIFICATI-ONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLF� D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA,r _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSSdu -- U TYPE OF CASING_ D STEEL If PVC D OTHER:_ <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 3 , ' I KLMIL I YF'E I U Lit USEU: II AUUEHS D HOSE <br /> Q AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 57, 32f¢nef�.fd <br /> a OTHER: if OTHER APPROX.BORING DEPTH Z-0' b5 1 8CLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED D (;f YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this appliratinn and that the work will he done in accordance with San Joaquin <br /> County Or finances, Rul Q(d Regulations, and all applicable California State Laws. / <br /> .. Signed r Vim+ d Title/Company G1 1 t2e_eM� <br /> �r �... <br /> Print Name ,1 A 6 <br /> ,DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l as- <br /> WORK PLAN nATEQ: /V OV,2 <br /> Application Accepted By V I c,� r; Cc L . Date Issued avl <br /> Aea' SGrout Inspection ByVILL r <br /> Destruction inspection By — Finl Inspection BY <br /> Date (rue e y z v 7 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES Epp INFO AMOUNT REMITTEDEV�, <br /> CHECK <br /> RECD 8Y DATE PERMIT SERVICE REQUE37# INVOICE <br /> 3503 105.oa 384.95 24SSSR# <br /> da49 778 <br /> C-57 WCC WAIVER__ C-57 Letter of Authorization to sign Permit, Encroachment doe <br /> EH2�-02•Dl1l <br />