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COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> sSUED <br /> Application is hereby made to San Joaquin Cotyfor apermitt t NON-REFUNDABLE construct and/oPERMIT r install the workO LDATE I <br /> 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 Public Health Services,Environmental Health Division <br /> yC� Rc,�"nhcod Assessor' <br /> WELL Location <br /> C b14 Crass Streit City CU: �v n Zip `�'it r Parcel# �Z-'Z2-0 <br /> r• j� <br /> PROPERTY Owner Address 5�Dp 3 <br /> 7 7 f} ty� ail ti Zrp r ✓s hone#* <br /> C-57 Contractor 5T ; yyy�� Address 3133 rt Crag{ �BTGJ?C T �! <br /> t~ Cfty� r».- Zip , YZ-rc#! '' L ��1��honeN`��C� <br /> Consultant/Sub Contractor ' .rtb �-t-Address <br /> GIS CIj <br /> oordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER') <br /> [I SOIL p DESTRUCTION (choose type below <br /> RING# <br /> ff,WELL# <br /> ❑OVER-BORE <br /> 'Other Grout Specifications 0 PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLDW STEM DIA OF BOREHOLE Lr MULTIPLE CASINGS"a YES"'NO WELL CASING DIA _ <br /> PQ EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSlty rTYPE OF CASING �S EEL XPVC 11 OTHER <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEALQ ; TREMIE TYPE TO BE USED <br /> AIPSPARGE Q PUSH POINT GROUT SEAL PUMPED Ay j]AUGERS [�HOSE <br /> j]SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> �TE MAXIMUM FREE-FALL DEPTH IS 30 ) <br /> ❑OTHER Q OTHER APPROX BORING DEPTH /C)5 Xf3OLTEO TRAFFIC BOX or <br /> p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? d (if YES list specifications here) <br /> 'COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinances, Rules Wd Regulations, and all applicable California State Laws <br /> Signed x�&�- L L TitEe/Company <br /> Aj <br /> Print Name o' <br /> DEPARTMENT USE ONLY Date '© <br /> SITEM AP IN II NIT .nrrFILE, ADDRESS 5-4-61/0 �Y62 .04. <br /> WORK PLAN DATED. jQ <br /> �ll1Q fD44 O , <br /> Application Accepted By Date Issued ! ""lt 0 a D�� <br /> Grout Inspection By Date Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> COUNTING ONLY AID# <br /> C # <br /> IPE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMrr SERVICE REQUEST# INVOICE <br /> 5a l ug /3 00Z 3(P-21) <br /> C-57_-__ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dot 9/27/00 <br />