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WELT` HERMIT APPLICATION Rd—RM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Public Health Services,Environmental Health Division. <br /> WELL Location_ yykA#Vl Cross Street Assessor's <br /> p I City z Parcel <br /> PROPERTY Owne �1V1 1✓1 IMG fijgddress �• , O <br /> r Ci i��p Zp I Phone# <br /> 3-57 Contractor , , Address ( CI c&, ZI <br /> tY c# 1 I OPhone O -1) <br /> 2onsuitant/Sub Contractor A1/1 dresO") [/d � <br /> City Lic# Phone#(ClI L%I– O Li CL <br /> NS Coordinates:X Y I Townshi <br /> P Range Section <br /> VORK TO BE PERFORMED: <br /> I NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 13 SOIL BORING# 13 DESTRUCTION(choose type below) <br /> 11 WELL# 11 OVER-BORE <br /> Grout Specifications: Y �� �j PRESSURE GROUT <br /> OM <br /> OMMENTS: ��� V�jn`�" <br /> (PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[I YES 0 NO WELL CASING DIA: <br /> EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL ll PVC Q OTHER: <br /> TREMIE TYPE TO BE USED: Q AUGERS (]HOSE <br /> 41R SPARGE Il PUSH POINT GROUT SEAL PUMPED: p Yes [)No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: <br /> )THER: n OTHER APPROX.BORING DEPTH <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> OMMENTS: CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <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 /> ereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> unty Or finances, Rules and Regulations,and all applicable California State Laws. <br /> led x �---- Title/Companyr– <br /> tName � v'1 1 �-' U <br /> DEPARTMENT USE ONLY Date �— <br /> E MAP IN UNIT IV FIL DRES <br /> IRK PLAN DATED: <br /> Ication Accepted By Date Issued QQ <br /> t Inspection By ate ea. <br /> Date Final Inspection By <br /> ruction Inspection By Date <br /> MENTS/CONDITIONS: <br /> 30UNTING ONLY. AID# k. <br /> cer�e <br /> ODES FEEEINFOAMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST# INVOICE <br /> t 2 .00 04- g � 1 rs' o sR* �O 3 <br /> WC -WAIVER C-57 Letter of Authoriz ion sign permit Encroachment doc 9/27/00 <br />