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iIf�` ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> - a Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siclov.oro/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 of San Joaquin County Environmental Health Department. <br /> �i�.� Assessor's <br /> Well Locatton ZS37br,Wflkloa Q� cross Street r w7o Ave city !�toc k�-O� zip Zof Parcel# 10-140-035— <br /> Property <br /> Owner UAN#-(A wi lVabuc- Address 4115 *9tfAoJ Ajer- city S�bcKfy4 zip ClYz Phone#Z6 A -Sy3r <br /> e D q/b fiS3- a/o <br /> C-57 Contractor T���r" �N"•'�CY�L Address ASO rnMl/� rrll?k pfY�CECity/19rtc`o zipG57YL Lic# _Phone <br /> Consultant/Sub Cntrr�tEo"A6,9WIK6Address-213 JQ445Sf City L&A t'A- Lic# Phone fOf64z-1468 <br /> •�v i a e <br /> GIS Coordinates:X 3! 5% 3 q•SZ Y 12-f If .66 ,Township Range Section <br /> K TO BE PERFORMED: <br /> NEW WELLlBORING(CPT,GEOPRO1915,HYDROPUNCH,HAND-AUGER.OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# vp { VA Z_- ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1 ' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMtE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE POPUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes LWNO (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) J <br /> PSOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS (hirt"" <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE c <br /> COMMENTS: CONDUCTOR CASING PROPOSED (If YES,Est specifications in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I plicable Cates la Laws. /� <br /> Signed / Title/Company (�rvtli ✓Ll/f lei T'NC- <br /> Print Name M 6g1q C w1A,F Date S�LT�ro <br /> 1 <br /> DEPARTMENT USE ONLY t 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oZ�3 tit )�yt.�.1cflJ i �'�`OC/t✓rl1 <br /> WORK PIAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 1,9,40, S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35.0 a OV 8S' G o SR#ov/GeIf <br /> C-57 WC -WAIVERC57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01„0128(09 ���I �``(� � � � WELL PERMIT APP <br />