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1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. / As essor's <br /> WELL Location Z?Y 1 �/9G�IC�L Cross StreetCFn1�:?�1L CT- City aU4 c� Zip ��Y Parcel# I f 3 3 //',/" 3( <br /> PROPERTY Owner Irluv �C'f/xrp 6i% AddressZ74 tont ( ✓err.! City(�oVr�To ZipQ Phone#LZIA d <br /> C-57 Contractor >N[ D k& / OCAddress S dam✓ &� City I�CI�T�J Zip /#Phone# / (f �aCsv <br /> Consultant/Sub ContractorACr{cslalVle Address Ffi�i7cI,�AL.� �at� City�riC?TJ��Lic#G7�Ju�Phone#�Z������lcYi(o <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BEP FORMED: DESTRUCTION(choose type below) <br /> ANEW WELL/ O (CPT,GffIL <br /> ,HYDROPUNCH,HAND-AUGER,OTHER') 0 0 OVER-BORE <br /> 7'� RING# 0 PRESSURE GROUT <br /> WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,/^ <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE` _MULTIPLE CASINGS?0 YES )<NO WELL CASING DIA: /NA+ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL(JAL TREMIE TYPE TO BE USED: h AUGERS HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> ,0`OTHER: p OTHER APPROX.BORING DEPTH &) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> L/( CONDUCTOR CASING PROPOSED? (if YES,list specifications ere): <br /> 'COMMENTS: 1 61 L l 6 D r 10�J —a botjI? D{�t C <br /> E� 541, E r cL- (L-L z fD� <br /> NOTE: OFFSITE BORINGS REQUIRE A CESS 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 preparpd this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules arm Regul ions,a d all plicable California State Laws. r r / <br /> Signed x <br /> ` / Title/Company Vi'LlJ<-�`��$//►RJV� LE� r t �I/i� 1�TA L <br /> Print Name �L S Date GS�o�oZ <br /> DEPARTMENT USE ONLY�— <br /> SITE MAP IN UNIT IV FILE,ADDRESS: P <br /> WORK PLAN DATED: �c/� Area <br /> SEG <br /> Application Accepted By �, C�J ate I ued ! 1 GL CW <br /> Grout Inspection By 2 e [�3pectiorB v i/Date �1 <br /> '0 00 <br /> Date/ / <br /> Destruction Inspection By N\ <br /> / ✓ �g�\GFN.�P\HF <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY,/ DATE PERMIT I SERVICE REQUESST/# INVOICE <br /> C-57_ WC -WAIVER— C-57 Letter of Auth rizat nit si per it Encroachment doc_ 1/25/02 <br />