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gulry o SAN JOAQUIN COUNTY <br /> ..s � <br /> FILU'slffTEN A ENVIRONMENTAL HEALTH DEPARTMENT <br /> ttt 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 0 Z d <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v ` <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application is ma'M d S <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. h ` L EALTF <br /> Well (A?RR A� City Zip , 37� Parcel#,73515 OUZ <br /> Property <br /> o: Cross Street/ ' r <br /> Owner �� Address "2.5t City. NGZip�pi I» phone#�+!r y <br /> C-57 Contractor Y i I Address City MlIA14 Z Lic# �&S Phone 92S 9-S9?o <br /> Consultant/Sub CntrIL Address 210L Lt�,5LQ*f1gcity Oak[at Lic ' I� Phone.SIO' 03` y/On <br /> ti <br /> GIS Coordinates:X •73q v; - I - '�2Z Township ^ Ranc _Section _ <br /> WORK TO BE PERFORMED- <br /> NEW <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# TRY 300 "T'RY-A i ❑OVER-BORE DIAMETER <br /> WELL# <br /> ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: pQy �_�— ru s <br /> L� W. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1O <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1 3 p ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> Cl EXTRACTION ❑AIR HAMMERIDRIVEN 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 PUSH POINT(GP OR PT GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') \' ` <br /> SOIL BORING. HAND AUGER GROUT SPECIFICATIONS 1 =,r P0Vtjajj <br /> /❑`OTHER: ❑OTHER: APPROX.BORING DEPTH 5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) <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,a all applic le California La s. <br /> Signed g � Title/Company mEC 'j -D1� �x <br /> t <br /> Print Name —Audi t, Q�y (� Date -_7�/ 17 12D11 <br /> —10 <br /> DEPARTMENNT/USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /1 , 41- 677- rr�c-�s�WORK PLAN DATED: wt v t ��14 fit/ <br /> APPLICATION ACCEPTED BY DATE ISSUED -Z1�l� AREA D� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> oG2- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY ?DTE PERMIT/SERVICEE# INVOICE <br /> 3 r G V S R# Z (J <br /> -57 C -WAIVER C5 R EAUCUYTO SIGN PERMIT E C <br /> EHD.29-01 11/5/07(WEB) ��D ,73,!9gELL P MIT APP <br />