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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> All <br /> 600 East Main Street, Stockton, CA 95202-3029 ;' OOMITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www:sjgov,orgletid UNIT IV <br /> WELL PERMIT APPLICATION -­ <br /> COPY <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. 2ti j 50 41 <br /> 2 L Assessor's <br /> Well Location n U 1hLv^ �f, Cross Street ? lA I( .l k--- City o., ZipS 36�o Parcel# <br /> PropertyS�t n W a ort K o CA U$TF E3Al. P.0 Sox SS140(1 Los n e des 900 . �i -file, S ojoB <br /> Owner -1 S+ " �� Address - +�?-�a�- - City �o� Zips Phone - <br /> C-57 Contractor C� �?lil�i�c Address ?1D_$r)c_ot-7O City %odI Zip CI�Z�{ Lic# -777Phone <br /> Lor¢.3vy..1Ec <br /> Consultant/Sub Cntr c A. Address 2,000 0 p4.rt. ,:4z7 D<, City &'-o5eu:((e- Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW] I <br /> ❑SOIL BORING# ®OVER-BORE DIAMETER K we4(S <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS 6(fl—d iaf <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE [-]MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑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 ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment 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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all p4cable California Laws. <br /> Signed Title/Company Sfk¢f ,5c/Cr~�yfi / C <br /> Date <br /> S <br /> Print Name ��T n.1V1 (t r rISG H Z( <br /> DEPARTMEN={T- USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 3 4 /V l n 1 Yt ° 1 e 1 ' O <br /> WORK PLAN DATED: a 0 <br /> APPLICATION ACCEPTED BY �c+,-)y i Ci L " `G vQ Y+ `'� DAT`E/ISSULED S 3 0 0 i AREA��� <br /> GROUT INSPECTION BY 1�t.�Oci -,Yllt FINAL INSPECTION BY V I U10+lj�Ll ��r`)7�DATE 6 <br /> ' DATE JVJZ e- <br /> 1 d 1BY2Q0 P <br /> DESTRUCTION INSPECTION BJj;�i �dZ���� � sem_ <br /> COMMENTSICONDITIONS: O C4 Y-tie i'Ibn of M11A1- 1) 27 D <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 350 2 66, 00 4�• ad 302 53 `�2 .67130168 SR#005-4397 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 1115107 <br />