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SAN JOAQUIN COUNTY <br /> &.ARONMENTAL HEALTH DEPAR-I..ENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sicgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 oCity Ol� Zipf San Joaquin County Environmental Health Department. <br /> qR�,�*'S-� ZZJ �bra! Dy e • 1r 533 tP Parcel#Assessor' <br /> Well Location Cross StreetZ35'*5'DZ- <br /> Property )J ` -T( 5?b 60, V _lyd, Cit Zi ll 53 0 Phone 20) 60 <br /> Owner �l�� !}1- 1(GZC� Address —'-3b5 <br /> �7���"" �I � is y p ���1 <br /> C-57 Contractor �,�1, t tsr\ �IA M,Address �u�5 �vl I� City � � Lic# (DJ 697Phone /&Cq)o5 C?�2 <br /> Consultant/SubCntr L1 f�rUlVlfp In I Address 2395 (F•��SCAd(y(1 Ue City lya�l Lic# 5)561 Phone <Z008C 3''0?5u <br /> 6rviCeS Inc. <br /> GIS Coordinates:X Y Township Range Section <br /> _"RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA'.OF BOREHOLE W9 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL)XPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDXAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes XNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> 1 �gj <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Z 5 / BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 I CONDUCTOR CA ING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:�YVS �� 3 - ( U1�f 6111�()Y111A _010 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I h ve prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all apale California L l <br /> Signed Title/Company SI T �I VI b UIC�S #� <br /> Print Name Date 8 1 2 00& <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: IrA k <br /> WORK PLAN DATED: 1. 2- lie, <br /> APPLICATION ACCEPTED BY t/t+c `'�^r[M DATE ISSUED 01.1.;a,Los AREA <br /> GROUT INSPECTION BY � ,v.r�r,�._ ( � (I t I C56 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 /> •- <br /> o rsov zlsYl q ���� SR# S SS6) <br /> C-57_ _WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�ENCROACHMENT DOC <br /> EHD 29-01 1 5/.5/07(WEB) WELL PERMIT APP <br />