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i <br /> 4 <br /> WELL PERMIT APPLICATION FOM SITE 1 <br /> SAN 'JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 : <br /> (209) 468-3449 <br /> .6 <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 3 _ Assessors <br /> NELL Location Crossr�Street r1� City�T+— Zip_/ Parcel# �V 1 1�(�"'—jC� <br /> 3ROPERTY Owner IV► N� Address Pb 6�2 ?f/-Z Zi rr� <br /> ) ( �} '� 7 Cit)r p j�� Phone <br /> 57 Contractor Ili ^J it 4",�tJ Dr It �' Idress t�b�C' - ��- CCity�;1C` 1� t$ �7ILic# phone#7-, 7-37`f'f3L-c, <br /> :onsultant l Sub Cnir s4 �C Address 7S{n(C( c t 4 Cit Lic# Phone 1�1��? <br /> __. l <br /> 31S Coordinates:X Y Township Range Section <br /> 'YORK TO BE PERFORMED: <br /> W WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# []OVER-BORE <br /> SWELL#_P? 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> 30MMENTS i <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )'MONITORING iLHOLLOW STEM DIA.OF BOREHOLE "Y ULTIPLE CASINGS?QMULTI-LEVEL?0 WELL CASING DIA: <br /> I EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS N4- TYPE OF CASING: '0 STEEL 0 PVC j]OTHER: <br /> }'VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALY4[/�6 TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> I AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: *es j!K_No (NOTE: AXIMUM FREE-F&L, DEPTH IS 30') <br /> !SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: 0 OTHER APPROX.BORING DEPTH }` OLTED TRAFFIC BOX or Q STOVE PIPE <br /> h� r <br /> CONDVCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> =I <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 /> hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin <br /> :ounty 'Ordiinaances, Rules and Regulations,and all applicable California,State Laws. IIt: <br /> igned x `�'(_ x4-.1t._-- k<Cdti- TitlelCompany <br /> Irint Name _>I/(�/ I• Fr L-t�L/I " Date ZO^)3.- <br /> DEPARTMENT USE ONLY <br /> ,ITE MAP IN UNIT IV FILE,ADDRESS: �-t LAI ' <br /> VORK PLAN DATED: "- <br /> pplication Accepted Bye Date Issued ! U Area <br /> ,rout Inspection By. Date Final inspection By Date 2221 <br /> M <br /> )estrucGon Inspection By i Date - <br /> :OMMENTS/CONDITIONS: LA) i ` �,t �- � � '. U <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 3S61 99 SRU <br /> �$ <br /> -57^ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />