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SAN JOAQUIN COUNTY <br /> ENS, JNMENTAL HEALTH DEPARTM t <br /> Q� -� TE <br /> too: <br /> 600 East Main Street, Stockton, CA 95202-3029 1 TION <br /> P Telephone:(209) 468-3454 Fax: (209)468-3433 Web:www.sigIV <br /> WELL PERMIT APPLICATION 'LIL L :cUiO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE isfi IRONIMEN IHEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appIlI tlbff(Tw,�/ ance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Q Q ) <br /> Well Location Z"cXGf An Cross Street � CLi`t'y Tr1 � Zip 9 5 2 3 4 Assessor's <br /> Parcel# 12 <br /> t <br /> OwnerWG [2o[,,zr� G rLu1Address?qo f Crow /? N?I A IASAA) <br /> Zip9us93 Phone <br /> 9 q•lo g/D <br /> ✓ 2 <br /> bass <br /> C-57 Contractor r $C� �r�I� '7�l�q Address 3 I$0 �oHgCsLon /12���] City JCS V' �C Zip�S s 4 7 Lic# 6 8 3865 <br /> ConsultanVSub Cntr A RCA,.1 I S Address 140 711 JT•� 00 City ?CJ47 IU 1,%4 Lic# Phone707.176.0S 6S <br /> GIS Coordinates:X Y Township J Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROB I�YDROPUNCH,HAND-AUGER,OTHER-) , ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> Q?SOIL BORING# 1 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> El DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IN11 <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z•;`1AE1 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:ElSTEEL ElPVC ElOTHER <br /> ElVAPOR ElMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE XPUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes E]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> / <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS /"e?f CQpileoiTL <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2 O res T ❑BOLTED TRAFFIC BOX OR ❑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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations;19.4 <br /> all appli I California Laws. r J <br /> Signed ^ti * Title/Company 54AFF 6COL0615T �" f S <br /> Print Name Ame) M. 1 C(kles0i Date 0712 9/ 20I D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a / Com[ ! V <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY • 'L AREA D� (j <br /> GROUT INSPECTION BY U FINAL INS PECTIUN DATE�a 1/6 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> D 0a-� 7SR#W680 of <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE F I� MPENT DOC <br /> EHD 29-01 10/28/09rJ WELL PERMIT APP <br />