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' ��i/ • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.segov.org/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 ,Develo ment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> .,V,2,4e sh' X,14 45 elc 7AO-e- oA-1 _ _ Assessor's <br /> Well Location Cross Street 0 City Zip/S.?7 O?a_/ <br /> O <br /> Property �/J�J(111/ ({rte/jI <br /> Owner )e'Ial Z,D/' C�UL��O '/f��ress IXIO E/iii Lt`L�C1�t�City -S f2'CI�O✓Zip 9�1 W Phone#C�// F_��3 066 <br /> C-57 Contractor ess �/�d �PWy 40'��City uc#7�y Ph 7700 6 /dd/7 <br /> Consultant/Sub Cntr Address City r,� Lic# Phone r -" <br /> GIS Coordinates:X Y Township J�"'�' Range Section l6 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPWDE.HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING J ❑OVER-BORE DIAMETER <br /> ❑WELL# / ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: /n/S!�PGG ff�/!J7✓ t��/Y�G✓ �ig/t/Q�/L L 4/iaf �/�//�/�IC�/O�� `✓�GL /1�r�/Pi� <br /> fir " w i / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ]HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION /❑AIR HAMMER/DRIVEN CASING THICKNESSO'�V TYPE OF CASING:❑STEEL ❑PVC OTHER HDPcrox n <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL jj TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FA L DEPTH IS 30') _ <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 'Cr ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED to> (if YES,list 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 all applicable <br /> qaj' rnia Laws. p <br /> Signed �� LJG(� Title/Company C <br /> Print Name Date �� a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED40 Og Z 7 AREA j <br /> GROUT INSPECTION BY FINAL INSPECTION BY /v� �� g <br /> DESTRUCTION INSPECTION BY DATE CE/VED <br /> COMMENTS/CONDITIONS: OCT 2 7 <br /> SAtj - <br /> ACCOUNTING ONLY: AID# FAC# H ENVIRpNME NC OUN7y <br /> PE CODES FEE INFO AMT REMITTED CHECiC7F' RECV D BY DATE PERMIT/SERVICE# I bI ] <br /> 447 r �� SST 2'1 6 ' jSR#005 ?7 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />