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r <br /> �. <br /> ,p U1 i an Joaquin County ,a <br /> a <br /> Environmental Health e r�'partment <br /> ITE <br /> i 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdSP'P Y i ��� UNIT IV <br /> Well Permit Application c€41VIt��JNI'VIENT tom°' P! <br /> NON-REFUNbABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PEW-flT/SERVICES <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 <br /> 'of San oaquin County Environmental Health Department. <br /> f`� w ' �� ZP- _,Cross Street /, Assessors <br /> WELL Location _ CityZipZ Parcel# J <br /> PROPER <br /> Owner Address 6V Cit4�CJZipphone# <br /> C-57 Contractor Address <br /> Consultant 1 Sub Cntr 4)3�Z?!q— Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WO IC TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOP_R08F,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> Q SOIL BO Nle# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> ' COMMENTS: e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI ATIONS <br /> Q MONITORING Q HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS . TYPE OF CASING: Q STEEL n PVC Q OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: )14-GERS a HOSE <br /> Q AIR SPARGE/OZONEg�PUSH POINT GP r CPT)GROUT SEAL PUMPED: U Yes Q No ( E: XIMUM FREE-FALL DEPTH IS 30') <br /> n-AOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> r 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 Ordinanc s, Rules an gulations, and all applicable California State Laws. <br /> � 2 <br /> Signedx_ f Title/Company <br /> Print Name Dale f !— <br /> + 1 <br /> DEPARTMENT USE ONLY ' <br /> SITE MAP IN UNIT IV FILE,ADDRESS:. <br /> WORK PLAN DATED: <br /> Application Accepted By + Date Issued j6 Are <br /> Grout Inspection By C_�. Date © Final In By Date Q <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE j <br /> 3sa3 �8s �$ 7 y SR# <br /> C-57 WC'WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122104 <br /> I <br />