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' SAN JOAQUIN COUNTY ���� 2 S �U ilk <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIR01MEN <br /> �,. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web.wwW,s' ov.o leh UNIT.IV <br /> �•...c� ogV <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 applica n is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dep rtment. <br /> Assessors <br /> Well Location-IM S S7 om-TWA Cross Street .56�L �� City P� Zip Parcel#01 <br /> Poairner Cl�K flF �tPn� pStNAddress 1% . �11-SM t.city �IP�1N zip.g,IWO Phone#1tg-S�-21Q <br /> C-57 Contractar6 drAddressZl(//j (/ L City 11 B Lic#V one <br /> tv <br /> Consultant/SubCntr�tl�Itd'I�YW� Address G44ij51CftC-ejnV"'fr,5fc•l- City JDWbrirt G } �RYy6ft Phone <br /> GIS Coordinates:X Y . ,Township Range Section <br /> RK TO BE PERFORMED: <br /> NEW WELUBORING(CPT•GEOPROBE,HYD R PUNCH,BAND-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 INSTALLATION1XPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING..s ❑HOLLOW STEM DIA.OF BOREHOLE 2.3-S ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> I ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY r� DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS HOSE PvC <br />'4 <br /> [3 AIR SPARGEIOZONE XPUSH POINT(GP OR CPT)C_P GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ` A CE �e1V"r <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 32� ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> j - CONDUCTOR CASING PROPOSED (if YES,rist spWficaWns in wmmem sedr0n) <br /> COMMENTS: <br /> E <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 pre aped this a tion and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an p <br /> I <br /> Signed ��'"����- Title7Company '/�i <br /> +�r <br /> Print Name t �' Date 0 <br /> i <br /> DEPARTMENT USE ONLY <br /> f SITE MAP IN UNIT IV FILE,ADDRESS: v aL <br /> WORK PLAN DATED: g 'Z- 0 Ing i76 ceJieF. c <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY ( S #D FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> i - <br /> I ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK 0 RECV'D BY DATE PERMITISERVICE 0 INVOICE <br />+ <br /> _3x'06 g3q•0o -3,5910 SR# bc,410 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> 1I EHO 29-01 1115107(WEB) - WELL PERMIT APP <br /> i <br />