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WELL'­�— RMIT APPLICATION FCi 1 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 =� <br /> (209) 468-3449 MAY 0 g 2003 <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 jr de in'Com liarli e�witfi�St� <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental,Heal h D"v's�o <br /> //jj � A's'ses9o�s <br /> WELL Locationh �. (�� Cross Street City Zip Wel <br /> PROPERTY Owne, ll' rr"1 ►lnCAr nAddress Ci I Zip L� Phone# 2,DaL5 OA-%(.>S <br /> C-57 Contracto ddres� Ci a i�Zi #��1�1 Phone "I�� Jr� <br /> Consultant/Sub Contracto ddressi Ci GC. Lic# Phone "I 1 (G'1-0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )6ONITORING XOLLOW STEM DIA.OF BOREHOLEii ''-- MULTIPLE CASINGS?a YES>aO WELL CASING DIA:��/ <br /> `T <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESW) -0—TYPE OF CASING: 0 STEEL_%!%IVC 0 OTHER:_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I) L�;)L TREMIE TYPE TO BE USED: 0 AUGERS > OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:,)Oe ONO <br /> (NOTE: M IMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: t-� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH -f"1 OLTED TRA IC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?___jtQ. (if YES,list specifications here): <br /> 'COMMENTS: <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O a es, Rul d Regulations,and all applicable California State La7s. <br /> Signed x �-� Title/Company 1 C�PX � ZSE�'_� <br /> Print Name �L `e Date J I_'f l l L' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �L 1 r Date Issued J / 2 < Area <br /> Grout Inspection By D Final Inspection By . Date�J <br /> Destruction Inspection By Date c <br /> COMMENTS/CONDITIONS: h AC <br /> 113 <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D PY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 8` .oa "v 22 d SR# <br /> C-57 WC=WAIVER C-57 Letter of Autho i zat�sign permit Encronch ent doc 9/27/00 <br />