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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> y Z{ <br /> !. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> q <br /> SYM <br /> ne:(209)468-3454 Fax:(209)468-3433 Web:wvvw.sFgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NOV 19 200009 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 5NVWUWC99' W County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Count �M' fc ter 9-1115.3 and the Stan ards of San Joaquin County Environmental Health Department. <br /> f �'- Assessor's <br /> Well Locatio� Cross Street ��trl S City _ 1 �07,44 Zip Parcel#--- <br /> Property _ I /�� Q� I' <br /> Owner_ �►'t�175 ��T• �n_,—� Address�_L[� //I/MLK �/�'��_ City dA 9? <br /> [nZo.�,IvI,,�Phone# -log 7�73 <br /> C-57 Contractor �'AddresJbv��IDT Y�/Lp - �i� wLip ZJ/�s'�ic# 7��� Phone <br /> ConsultanVSub Cntr__ AddresJ1b�� #lZ�!_uc ity <br /> -3 /5 -ra-r. X 374,&3 <br /> GIS Coordinates:XN_ -(-_—­Township Range-----_- Section _---- <br /> WORK TO BE PERF'OF MED77O2 —IOZ� ak"Z�ds <br /> ❑NE"ELL/BORING(CPT G OPRO E,HYDROP NCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) — <br /> J�SOIL BORING# ❑OVER-BORE DIAMETER— <br /> ❑WELL# _---- --- F1PRESSURE GROUT <br /> ❑*OTHER _—__------------------- GROUT SPECIFICATIONS <br /> EXPLOSIVES DETONATING CARD <br /> COMMENTS: al-la <br /> ��GYI `�a�3.C.0 li ' '' ---- —/� Cl/J�L�------ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER _ <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER _ ^, ,L} GROUT SPECIFICATIONS /�y�� _ <br /> ❑OTHER: ___ ]OTHER f APPROX.BORING DI I-�� 1 __� BOL-�D TRA FIC X OR [ISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:_ <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 applic nd that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable 0 aw, .� <br /> Signed --_____Title/Company <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 c� -------------------------- -- ------ <br /> WORK PLAN DATED:-- � 1� --_ --- — -- <br /> APPLICATION ACCEPTED BY DATE ISSUED O AREA <br /> GROUT INSPECTION BY _—__— FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY_— — �,, .• --- DATE-------------- <br /> COMMENTS/CONDITIONS: --�� , -- — oinlw La� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC _---___-WAIVER _ C57 LETTER OF AUTHORIZATION TO SIGN PERM11T _ _ ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br /> 7R—S3//D Z / �� fD <br />