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+R' <br /> .N San Joaquin County <br /> SITE <br /> Environmental Health Department <br /> N: { 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> 0" Well Permit Application <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 t9-1115.3 and the Standards ofSan Joaquin County Environmental Health Department.Assessors <br /> WELL Location <br /> Z Q S u/ 'Zy Cross Street V Unn I n^ City S c, <br /> PR <br /> Zip q--320 Parcel# `LOS -ZS(y-�y <br /> PROPF I S�.� L 1`7-zo tM 'L Y L qq <br /> Owner +S �tAddress Aj2 Cit SC'tt lG°r� Zip 1 S Phone <br /> ( (� f / d; G <br /> C-57 Contractor l`7fe��i Uf �li�L Address qSd 'td��2 �d City E�Sr zipYVY20Lic#rto7 Phone# �ZS'3I3 <br /> Address 6 ZZ ►-J Is City r�r+ �a^, Lic# Phone# <br /> Consultant/Sab-erftr _ <br /> 3 b <br /> Range Section <br /> GIS Coordinates:X I I I 3 3,�3,Y 3� S Township j <br /> WORK TO BE PERFORMED: R*) p DESTRUCTION (choose type below) <br /> A KIEW WELL/BORING (,CPPT�GE6 ,HYD-_ OPUNCH, a OVER-BORE. DIAMETER <br /> SOIL BORING# PRESSURE GROUT <br /> ! 0 WELL# GROUT SPECIFICATIONS <br /> ' 0*Other <br /> i <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLEZ-,'1 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS t1 LIN TYPE OF CASING: Q STEEL 0 PVC a OTHER: <br /> p VAPOR MUD ROTARY DEPTH OF GROUT SEAL $0 TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yesla <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS �d BOLTED TRAFFIC BOX or a STOVEPIPE <br /> OTHER: C 07 a OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED ✓1 '� (if YES,list specifications in comment section) <br /> j COMMENTS: <br /> _.-. <br /> - - _ - <br /> NOTE: OFFSITE-BORINGS REQUIRE ACCESS AGREEMENT 0R ENCROA <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 in accordance with San Joaquin <br /> County Or an es, Rules and Regulations, and all applicable California State Laws. <br /> Signed x� Title/Company Geolo ist/Kenne �/Jek�sCon�sujtantsInc. <br /> Print NameMike McLeod, P.G. Date 9 r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A 1 SS O <br /> WORK PLAN DATED: as <br /> Application Accepted By _�.�(�r <br /> ,��.� ,, Date Issued I I�► O Area <br /> Grout Inspection By <br /> Date Final Inspection Byj r. Date 2 0 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# Li� y � <br /> C-57_ WC—WAIVER_. C-57 Letter of Authorization to sign permit_Encroachment doc- <br /> EHD 29-02-001 <br /> 6/22/04 <br />