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06/14/2001 12: 59 2094683433 FIF-H FLOOF P-GE 03 <br /> WELL PERMIT APPLICATION F 7-RM SITE <br /> SAN JOAQUIN COUNTY PUBLIC 'iEALTH S1 = VICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PH _HD) <br /> 304 E. Weber, Third Floor, Stockton, CA., !) 1202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y=AR FROM D IT I SHED <br /> Application is hereby made to San Joaquin County for a permit to ccr.struct and/or install t.r­work de;cr De 1 nix,ap;icat on is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Jna uin Ccunty Public Ne.-I' Serviecs.Environmental Hcalth Division. <br /> Assessor's <br /> WELL Location 1Z-'�I) IZ7S, IZ9i YYl�S rt cross StrF�' Ci+yy��QC�Z;n Parwl# LI -340 -(4 <br /> r p ( /� �/ Z!b—340--iS <br /> PROPERTYOwner�- (`V, � :��O/i'}�4�-gddress 290( !1 ttr� pc,�Clty /( K6_Ziir 9S?-CoPhone:. <br /> C-570 ctor Ln T r-') Address�_�0�}3 �7CI-tuV;f _zgS9�-1i t7�0� hone# G�/ 15 /-2a9 <br /> Consultant! ubContractor Li e 1, tl r,V (( _ _4k Phones / ��-f3 `T--j <br /> i clP�r' Addr_s= Cify Lir_ <br /> c r� � � 9 <br /> GIS Coordinates:X ,Y -Township_ R:� __ / L Section <br /> WORK TO BE PERFORMED: <br /> �EW WELL!BORING(CPT, EOPR02 YDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> ` 0 S RING 9 0 OVER-BORE <br /> p WELL F p PRESSURE GROUT <br /> 'Other; GrcrtSpeC'tir�tionS:��Gz _� �17� <br /> COMMENTS: <br /> TYPE of WELL INSTALLATION TYPE CONSTPI ICTION SPECIFICATICNS <br /> 0 MONITORING (I HOLLOW STcM DIA.OP;;)REHOLE 'MULTIPLE C;.SI _ -; 0 YE= [ No WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMERIDRIVEN CASINa THICKNESS _TYPE=F I G-. F S rEFL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH DF GROUT SEAL TR_' :- YPE T BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOT rAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: _ _ -- <br /> a OTHER: 0 OTHER APFFZO>' BORING DEPTH 13 _TED'F�A=FIC BOX or 0 STOVE PIPE <br /> CONDU:TOR CASING PROPOS-D7 1 5,lis:-,p.--c fixations here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCF ) ,CHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORMING HOURS IN ADVANCE FOR l L RE )UIRED INSPECTIONS, <br /> I hereby certify t at I have prepared thi pplicat on and that the w irk will be Jc c In accordance with San Joaquin <br /> County rdina ees, Rules and Regul -ons, and all applicable Cali`ornia St,-t(- <br /> gned x _ Title/Company�� LC /�T �•21 Y! 214 2 <br /> Print Name 'ITQ—UU�/ ¢ ^ v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: F I L E <br /> WORK PLAN DATED' �/� <br /> Application Accepted By �� I l - .� ` Z� _ Date Issued to + Area 7 <br /> Grout Inspection By ;:in 4 Inspection 3y O <br /> Destruction Inspection By Da _ <br /> COMMENTS 1 CONDITIONS: - <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK = REC'D BY DATE ` ' F ATT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization 11o s�qn permit_ ncrocch hent doc 9/27/00 <br />