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1 <br /> U ` SAN JOAQUIN COUNTY <br /> '3EP z6L 2008 <br /> t ENVIRONMENTAL HEALTH DEPARTMENT' SITE <br /> = 600 East Main Street, Stockton, CA 95202-30�1ViRONI�/IRI-i HEAD ffiGATION <br /> . c <br /> ., (209 <br /> Telephone:Tele <br /> p )468-3449 Fax:(209)468-3433 Web:wwwsig�h2lFntJ1(;F, UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> / / Assessor's �p <br /> Well Location r Cross Street -, Ciry„�(,J_LiOI, _Zip 75zlo Parcel#090 440—0( <br /> Property � r${{-0 e C(' City p ::I— <br /> Owner Address Ci Zi Phone" <br /> C-57 Contractor &44"II C-A!76rr*004dress t c@7 --Lic# Phone LaiZl <br /> Consultant/Sub Cntr AQ4DfJ Address 9S0 (aaw.Dri c 51 t2S City - IrV_fo^ , [A_ Lie# Phone(9/O 9$t-2,0 79 <br /> GIS Coordinates:X ,Y Township Range Section <br /> I fPRK TO BE PERFORMED: <br /> X1 NEW ELL/BORING(CPT,GEOPROBE HYWUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> X1 SOIL BORING# S'J3-/ ro�g�h SLQ-� ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: / <br /> �{u✓tJ PAwtat/L. G rLgec� unde/PesOonStble CJtirw of MrGgacl P(ersc{IrKr <br /> `6. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE // <br /> ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL I]PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes XI No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> `SOIL BORING 'OHANDAUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH G ❑BOLTED TRAFFIC BOX OR ElSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in wmmement section) <br /> COMMENTS: <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 application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I applicable California Laws. / A�y <br /> Signed 7 /�It�� Title/Company FAICCt C xA(,U/- ZAM 01r <br /> Print Name 31EA/ Date <br /> •1 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( l f17Ya,Liy�J <br /> WORK PLAN DATED: O�3 <br /> APPLICATION ACCEPTED BY `--TV" DATE ISSUED /O/ fit/10-e AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENT$/CONDITIONS:/'k rr�. In <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMIT/SERVICE# INVOICE. <br /> aqo ( $� 2� 9T/S vih pg SR# 55-713 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> E11029-01 11/5107(WEB) WELL PERMIT APP <br />