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F Y <br /> D <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si_gov.org/ehd UNIT IV <br /> 4C/koR`' <br /> (� 5 WELL PERMIT APPLICATION L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ON' 15U6(-0 I <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 /> Assessors <br /> Well Location 77-D E. 6 f ti STRE�FTCross Street Yyl AGA v RTI•/61t City J fZ 6(-Y Zip qS ?e Parcel# 7- <br /> Propert• <br /> Owner_V PR,R (JIM DIEL) .Address Cl4Sl City RoSfiytt-LE Zip 'fS747 Phone# 0116 -7th`II-S) <br /> C-57 Contractor F V4lz V C 0 NSOLTgtITAddress 13 041 E F1 a fL a w-r.Av5 City SAufR ff 5pf W&s Lic# hone S 6 2-9 of -o 6, T I <br /> Consultant/Sub Cntr A 1Z GA DIS Address 14 0 5FL i)IV P &17 E ET City QET IQLV 1%A Lic# Phone Sl0 -,S9 b-?619 <br /> GIS Coordinates:X Y -12,00 Township Range Section <br /> Vi�K TO BE PERFORMED: <br /> M NEW LL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ff]SOIL BORING#_. 1 y 4 6'f SP O VTS (PI VRE Z O��✓Q) ❑OVER-BORE DIAMETER <br /> E]WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <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 14 PUSH POINT(GP OR CPT)CPf+GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,/ IF <br /> L10 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3y fy B e S ❑BOLTED TRAFFIC BOX OR ❑STOVE 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 /> hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and applicable rnia Laws. h <br /> Signed Title/Company A a n�S <br /> Print Name M r-.�f ssm ST RAT EN Date '901 (7 <br /> DEPARTMENT USE ONLY U O <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 72-0 � <br /> WORK PLAN DATED: "0 <br /> APPLICATION ACCEPTED BY DATE ISSUED <br /> AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 240 C) C!>,L) R# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />