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c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT --- <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web;Www.s' ov.o (��� ON <br /> WELL PERMIT APPLICATION �p10 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 �r?,'� n <br /> -- YEAR FROM DATE IRSt lFn ����HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This appli� Gr+ <br /> Joaquin County Development Title,chapter 99-11/115.3 and the Standards of San Joaquin County Environmental Health Dep. wth San <br /> Well LogtionUr"""moss Street C Assessors <br /> Property 44eu -_/ ltY ZiP� Parcel# <br /> Owner y'"42m Address Y f 4& f141&—Cj -C��,�. �•ip Zip�Phone 0 <br /> C-67 Contractor Addre /_r�`/�"""t��' ��/ <br /> City Zip Lic#<=L`-JTc Phone <br /> ConsultanUSub Cntr Address �/��City LIc# Phone <br /> Gia Coordinates X Y Township Ren ` <br /> t7e Section <br /> WORK TO BE PERFORMED: <br /> /C NEW WELLII3ORING(CP7,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORT <br /> WELL# ❑OVER-BORE DIAMETER <br /> 'OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCCIION SPECIF1GATlON3 <br /> MONITORING DIA.OF BOREHOLE �/ <br /> JMM HOLLOW STEM �•_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS. �/ TYPE OF CASING:❑STEEL At PVC ❑ OTHER <br /> n VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _52! TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yee ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS C /- <br /> . <br /> ❑OTHER ❑OTHER APPROX.BORING DEPTH d <br /> CONDUCTOR CASING PROPOSED! JYBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: T YE9.)w lw- talion.n aimmem sci n) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORMING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prapared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 1 0-PPI. California Laws. <br /> Signed TNIe/Company <br /> Print Name Data <br /> f DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:: 12 N il'Y "r Q__,, 4 <br /> WORK PLAN DATED. U tS 2-G ZO O <br /> APPLICATION ACCEPTED BY DATE ISSUED b AREA. <br /> GROUT INSPECTION BY FINAL INSPECTION BY ]� DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: C' S AtW LoP Stf. b <br /> ACCOUNTING ONLY, AID# FAC# <br /> �E CODES FEE INFO AMT REMITTED CHECK# RECV D 1:11 DATE PERMIT/SERVICE# INVOICE <br /> .!J► 85 2-3 e>'30► <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGM PER IT ENCROACHMENT DOC <br /> EHD 28-01 10/28/09 <br /> ^^ WELL PERMIT APP <br />