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4� SAN JOAQUIN COUN Fly <br />+ I <br />ENVIRONMENTAL HEALTH DEP T <br />600 East Main Street, Stockton, CA 95202-3029 7TNI <br />TION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />A ` IV <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T -A t%1I06?15�/ <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />Well Location ° tiSl Mc H e^'4A v2 Cross Street J • r`e 5 Ro a d City Zip '95732 o Parcel # <br />Property <br />Owner QIA�\\;o LioMvAak;% Address ^zo'151 Mtiie.!� Ayyt— City EstcAICA- Zip ctST20 Phone# <br />C-57 Contractor V k w o e".01 ^ q ,Sv.c, Address 3806 pvch- C/ee L Dr. City 5+00 -'fin Lic # -710 % Phone H t q - -080 <br />Consultant/Sub Cntr V 4.,u d: 5°5° —Address t?/s+. <br />y City E S c a lw. Lic # Phone 9.3 5-- I t Ffr <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />PIEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />SOIL BORING# - s91 - 10 ❑ OVER -BORE DIAMETER <br />WELL# ❑ PRESSURE.GROUT <br />[I *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q -MONITORING- -- -- ❑ HOLLOW STEM- - - --DIA. OF BOREHOLE V4 <br />--E]TVfULTIPLE CASINGS-❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION ❑ AIR HAMMERIDRIVEN CASING THICKNESS AIA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 'Lo TREMI6 TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE PPUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes P No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />`SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS AJ- -,+ Ce, -t ✓ -I- (,r.)- -- <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ° ❑ BOLTED TRAFFIC BOX OR []STOVEPIPE <br />COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all app\y'cable California Laws. <br />Signed Title/Company 5"ti <br />W (J'2dl0yISf Itrrp,-d Zeiy A,47S 'S Z' <br />/ �c <br />Print Name J u e- v 0eS 'jam - Date I I/ Von <br />inDEPARTMENT USE ONLY <br />SITE MAP IN UNITW FILE, ADDRESS: <br />WORK PLAN DA <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DATEISSUED <br />FINAL INSPECTION BY <br />Jai <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY DATE <br />PERMIT/SERVICE # <br />INVOICE <br />_r7 ,A, <br />,. <br />It b ® <br />SR# L <br />_-VVHI V CR UO i Lt I I tN Ut- HU I HORILA i IUNJU,5MS4Wt4T ENCROACHMENT DOC _ <br />EHD 29-01 1115/07 (WEB) RECEIVED WELL PERMIT APP <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />