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WELL PERMIT APPLICATION FORM SITE <br /> Nf IGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UMT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) w <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 -n <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tV <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made&j:ompljance with San <br /> Joaquin County Development Title//', Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environme Ast olth Division, <br /> WELL Location Cw-23D I aP,; J t lrV & ,, ue- Cross Street City �.Srr, cKf'c •v Zip 95pParcel# <br /> PROPERTYOwner Permr' <br /> - cgzneeE Address f5"'3G /1k.�-rd " fi • City zLtDcsj � Zip_ R!w�(Phone# <br /> C-57Contractor G�veR,S.,r J?.F � ) +�n Address 9S'Uu.e f'( o° cl Cityar!`ivre�Zjp 9YSSic# yR•+/�TPhone# 9:i.f - .;/ '-1 "? � � <br /> '� ✓�—T tr . <br /> Consultant l Sub Contractor ) �( r Cav !'H %�.�. Address �k: J'c Z: Citystj��\ yb iLic# Phone# "2 � 9- ;Tc s"/ e <br /> GIS Coordinates: X., y., Township _j/V. Range G G Section ; <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> b�Cru,�EW WELL / BORING ( CPT, GEOPROBE, HYOROPUNCH, HAND-AUGER, OTHER`) 0 <br /> Y" ' SOIL BORING # .� OVER-BORE <br /> WELL # 3 OPRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,)KMONITORING HOLLOW STEM DIA, OF BOREHOLE �r MULTIPLE CASINGS? 0 YES ffNO WELL CASING DIA: .7 t <br /> 0 EXTRACTION 1] AIR HAMMERIDRIVEN CASING THICKNESS -�"h yo TYPE OF CASING: 0 STEEL XPVC BOTHER: <br /> 1] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALt 2/- 657 r TREMIE TYPE TO BE USED: 9AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOILBORING OHAND AUGER GROUT SPECIFICATIONS, /V� � r 4 srexT <br /> 0 OTHER: BOTHER ctnr APPROX. BORING DEPTH yet - l7o r gBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /11� ( if YES, list specifications here): <br /> *COMMENTS: Clrf % tblac { w cz //✓ h %oo t I �c�% !'D Y✓'-/ <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 Ord' ances, Rules and Regulations, and all applicable California State <br /> Laws. !n <br /> Signed , e�1{'-e �- Title/Company �St fTCrf J ��L� /w ✓ C` ' `r (Cfa <br /> Print Name � �c' // • til".Lti. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By- - - �'V v Date Issued z</e2 z9Z ZO� Area <br /> Grout Inspection By j U `� ate Final Inspection By Date <br /> Destruction Inspection B ate <br /> COMMENTS I CONDITIONS: V <br /> ACCOUNTING ONLY: AID# v <br /> PE CODES FEE INFO AMOUNT REMI TED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> tEncroachment doc_ 9/27/00 <br /> C-57_ WC_-WAIVERC-57 Letter of Autho zation o sign permi _ <br /> _ <br />