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N , San Joaquin County <br /> Environmental Health Department SITE <br /> W: ` 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> • cP 20D UNIT IV <br /> uu 3 i A� �i. s�► <br /> ��/FORS Well Permit Application - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE Jj�~ �' '`��'%T Y <br /> fRONH :NTAL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dekL8AdL T IfHij*RliA4ddhl+$Mje in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> IAssessors <br /> WELL Location Q �tiwaln Cr <br /> S Cross Street City Zip 1 2D Parcel# <br /> PROPERTY I <br /> Owner'2� k oA Sb!_"`-"ddress 7 Z 6 1 �3• tit,.n, o n CityS��� Zip'15 Z. Phone# <br /> b ' Y p� SLG16�hone# �i 2 S 2k -S$ <br /> C-57 Contractor �r-�e.a„ ��.' �,.-c Address�l� � '�� Cit � ' �e Zi 'D-- <br /> Consultant/Sub CntrS / CIO c P. Address Z 12 1 N. L, M o, City L rem Lic# U�I C Phone#���S <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORA <br /> NEW WELL/ ORIN (CPT, OPRO E,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# I S .c� 1 S- ZS Sts 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: lS e Kr�oc�lmr� LoC. ��S ( a c� (- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE A <br /> PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ra� (J_1Cay, �P'4 <br /> WORK PLAN DATED: _T^S 6.w• <br /> Application Accepted ByAVA <br /> Date Issued 7�S/j S Areag19 7 <br /> Grout Inspection By Date 0 S Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �_qo r - �a�5! (1�� 7�7os� SR# oa�fa �S <br /> 11 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />