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oAq'Iy SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> N { <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P.. Telephone:(209)468-3449 Fax:(209)468-3433 Web:vA W.sigov.org/ehd UNIT IV <br /> 9<%FORS` <br /> oft <br /> 2� C� � <br /> jL P WELL PERMIT APPLICATION x A r <br /> J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C V u IV <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 /> nn yf Assessor's <br /> Well Location 7 Z O E• 6�"Sff4cross street Irl k L fig(7 R 2Ir City f c.C Zip 76 Parcel# 7--5'0 01 0 3 <br /> Property n <br /> Owner U P R2 (1'IM r2ML) Address g 451 AIK tjSfrta}City Sose U;lid Zip 9$7 '7 Phone# <br /> 9U.##,100 ��//,�,� <br /> C-57 Contractor �Q FG(r D R I LLI AAGAddress 9 SO HO t.✓F RE 6T City M f4 l'ZTI N E Z Lic#`R-d-5/ ne <br /> Consultant/Sub Cntr A1C C-61>15 Address 140 5 E C P iu D ST2EaT City PG`TAL&tN A Lic# Phone 5710 -s96 <br /> SvIT6 zero <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW VYELLJBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) ED DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 'Z 4 •r Z 5ftP out (F14-u 2E!r«OFwP) ❑OVER-BORE DIAMETER <br /> WELL# 5 ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Ef HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z 7 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Z TYPE OF CASING:❑STEEL C31PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL--L 7� TREMIE TYPE TO BE USED[y AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(NP OR CPT)�GPT GROUT SEAL PUMPED:❑Yes [I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ?,^ <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS N i L P_ NSE Y�r <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 O �1 BOLTED TRAFFIC BOX OR C1 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> C <br /> e <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, II ap California Laws. <br /> f <br /> Signed Title/Company R L F}p 1 S <br /> Print Name (rte Qi I :G S e4 5•f f A}e.A Date 0I i <br /> 2 <br /> DEPARTMENT USE ONLY Zcl�6b p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7 ZO C.. _6�'/� AW�D <br /> WORK PLAN DATED: (p 9 <br /> APPLICATION ACCEPTED BY DA REA a <br /> GROUT INSPECTION BY �d 0 f Z ( a FINAL INSPECTION BY'— DATEa'l6fo <br /> DESTRUCTION INSPECTION BY- DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 0 21?6 4 Ll 101 sR# 8/ZI <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERM ENCROACHMENT DOC I <br /> EH0 29-01 11/5107(WEB) WELL PERMIT APP <br />