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< a."4�.Esd1 SAN JOAQUIN COUNT <br /> � ���® <br /> ENVIRONMENTAL HEALTH DEP _ SITE <br /> 600 East <br /> �.. 11102ci- � )Ain MITIGATION <br /> Telephone:(209)468-3454 Fax.-(209)468.9433 Web: v.or hd UNIT IV <br /> 6M <br /> WELL PERMIT APPLICANT HEALTH <br /> RMITISERWES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herwY made to San Joaquin County for a permit to const uct and/or Install the work described. This application is made in compliance with San <br /> Joaquin Count T-kyme C�,chapter&1115.3 and the Standard 0188 n JpequIn GouMy,Emironmentai Health Department. <br /> Well Location 2 t�7 Icuf;oA7 on c L,n S� r;S0r-; y Asaesaor's <br /> Property Cme 5> e City Sfu�iMt zip 9Su1 6 parcel III 6 / <br /> owner Address zip 52oL PhoneX <br /> Dr T stn city SinrGlw <br /> c-ST contractor _V/8oA1tX,j4W�nMLMKT:l9.?_�' iEGo GH&r2dfo . LP94I;F!E3_Lc#& Y _P SaI-Jl�('J <br /> CorqulhnUsub Crdr Ldndar twfl, Address J,flg F/�4 wi rrC� srl& L,# Prions Z _� g <br /> GIS Coordinaba:X 1 31 n f^m,Y Zr 61267.77 ,Townshl / Range—z5. ►His ZO}j0+3 <br /> WORK TO BE �Sy ED: Se 4• .c f t..c 4c L( <br /> *�5 <br /> El NEW WEL P (CPT, EOPROB , OROPUNCH.HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# <br /> O WELL# ❑OVER-BORE DIAMETER <br /> fa"OTHER ❑PRESSURE GROUT <br /> Are- t.�l l;�L) GROUT SPECIFICATIONS <br /> ^ ❑EXPLOSIVES <br /> �DETONATING CARD <br /> COMMENTS: AT A s `r bQ low • --Pwc <br /> f.W <br /> TYPE OF WELL INSTALLATION TYPE cgAmucnoN SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEMH <br /> DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS OMULTI-LEVEL WELLCASING OU;_ <br /> 0 EXTRACTION 0M HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER _ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAII� TOI TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGEIOZONE MUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yp 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER. 0 OTHER. APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED MYq wt'P'°btw+H mmw+wam) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby urtlfy that I have prepared this application and that the work will be done I accordance with San Joaquin CoUhV Ordlnancae,Rule and <br /> Regulations,and applicable CalMohn a. <br /> Signed /\ <br /> Title/Company <br /> Print Name 1 . i/ IA-C..n4 _ Date t� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z1O� 1(1�NVvi t•y�i(_ <br /> WORK PLAN DATED: O I• <br /> APPLICATION ACCEPTED B DA ISSUEDq/t {//c>- AREA <br /> GROUT INSPECTION BY , L (� FINAL INSPECTION B w ••M. DATE �r, <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> "cRs� g�.o> gq_e� �Ze4 cE till la SRO 5-1 4 <br /> C-57 ,' WC -WAIVER CST LETTER OF AUTMORIZATIONTO SIGN PERMIT,i ENCROACHMENT DOC <br /> EMD 2M 11012!109 <br /> WELL PERMIT APP <br />