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-? SAN JOAQUIN COUNTY } <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 9524 =3029 -a MITIGATION <br /> Telephone: (209)488-3449 Fax:(209)468-3433 Web:.www s ov or fehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> f� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 41 Application is hereby made to San Joaquin County for a permit to construct and/or install the warp described. This application is made id <br /> it Joaquin County.Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> F�,8A_ssessor's'Lsq-Z4 V05- <br /> Well Location Z�q "ST4C.Kloacross Street k6. �.CDN /�T(. City d zi.p A1W1146�III�#EAkTH <br /> Property �-�`l �•��_. yl v� city Zi 3�PIioW Ds <br /> C����—&PON Address p <br /> Owner hh <br /> l C-57Contractar�y�£�� �IL�WN6Address 'a Q City Zl fCZ_ Lic �t� Phone <br />€ <br /> Consultant/Sub Cntr - r Address��y15,� ��-� city QJQ1.1�, # Phone <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# t 51 '�C%LPRESSURE GROUT <br /> WELL#9*OTHER GROUT SPECIFICATIONS <br /> I — <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING HOLLOW STEM DIA.OF BOREHOLE1A 1- {�❑�MrULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS S Gt•``4 TYPE OF CASING:I]STEEL [ ,PVC 0 OTHER <br /> ❑VAPOR <br /> ❑MVD ROTARY DEPTH OF GROUT SEAL'? TREMIE TYPE TO BE USED LIGE�❑HOSE <br /> lI- � u otrr- WN"I` <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes)6 No (NOTE:MAXIMUM FREE-F, L E T IS 3b) <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> I' ❑OTHER: ❑OTHER: APPROX,BORING DEPTH ` ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> i.: CONDUCTOR CASING PROPOSED (if YES,list sped fications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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,ap a Callfor S. <br /> Signed TitletCompany <br /> Print Name G! Date <br /> OPY <br /> l <br /> DEPARTMENT USE ONLYFILE C <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z 3 Ct S 5 e� <br /> 4'^ WORK PLAN DATED: I Z- z to <br /> APPLICATION ACCEPTED BY DATE ISSUED -ell I AREA <br /> GROUT INSPECTION BY `�]rtMAGr�I/L I 1 13 I !fes f FINAL INSPECTION BY IA w A,,vim+ DATE <br /> DESTRUCTION INSPECTION BY DATE. <br /> COMMENTS/CONDITIONS- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERV ICE# INVOICE <br /> 3517( ! 2 AsVo.aa 3qI`{'6- <br /> - sR# 6 1­7-6S <br /> C-57_ S,�f WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2 -Ot 77!51 7{WE6I <br /> 3so33�b ' . <br />