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Joaquin County, 1 U SITE <br /> •, ,��� 3o q artment, <br /> Qu 1 6 2e705 MITIGATION <br /> nG Environmental Health Dep UNIT IV <br /> 304 East Weber Avenue,3xdFloor,Stockton,CA 9N� t <br /> " 468-3449 Fax: (209)468-3433 Web:www.s}�W HEALTH <br /> (209) tion,; Ml / RVICES <br /> P• Well Permit Apptica <br /> hcation is made in compliance with San <br /> NON-REFUTIDABLE PERMIT EXPIR>=S 1 YEAR FROM!]ATE ISSUE <br /> ermit to construct andlor install the work described. This aPP Assessors <br /> Sication is hereby made to San Joaquin County for a p � Palcel# <br /> App dent Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HeaZltph Department. <br /> 1 Joaquin County Develop � City <br /> L }4D 05f S Cross Street � - <br /> WELL Location 1`Phone# <br /> } �r zip <br /> `I ity <br /> PROPER 5' �G2 Address ' ,� hone# �tf J <br /> Owner G2Y7 ,l.} <br /> G_7� Address Y/S Phone# <br /> C-57 Contractor Address <br /> Gity_��Lic#�l <br /> Consul I Sub Cntr Range Section <br /> Y Township <br /> b GIs Coordinates:X <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> D NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER) ��OVER-BORE. DIAMETER_— <br /> <OIL BORING# �' p PRESSURE GROUT <br /> T1WELL# i GROUT SPECIFICATIONS <br /> �"Other <br /> t <br /> COMMENTS: l <br /> 4 TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC IONS <br /> U MONITORING D HOLLOW STEM DIA.OF BOREHOLE-2=111" ULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA; <br /> U EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: D STEEL D PVC 0 OTHER: <br /> D VAPOR MUD ROTARY DEPTH OF GROUT SEAL° ' TREMIE TYPE TO BE USED: flAUGERS D HOSE <br /> AIR SPARGE!OZONEOUSH POINI�r CPT)GROUT SEAL PUMPED: D,Yes '�Al'F5Io/(NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH ii D 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 ICalifornia State Laws. <br /> Signed x // Title/Co'mpany <br /> �G <br /> Print Name / C- f` j <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �� v� Date Issued 1 1 �6 Area <br /> Grout Inspection By Date final Inspection By ate <br /> Destruction Inspection By Date i <br /> .COMMENTS 1 CONDITIONS: S it <br /> ACCOUNTING ONLY: AID# FAC# +v .�..,,1 C_�S^i' 'Z? C»J � <br /> I 6 " <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE ' .,L9Y DATE PERMIT I SERVICE REQUEST!# INVOICE f <br /> 350 - V L �3 sR# 2 g . <br /> C-57 WC--WAIVER— C-57 Letter of Autho I fio to sign permit_Encroachment doc� <br /> EHD 29-02-001 <br /> 6122104 <br /> xi ' <br />