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U9 if San Joaquin County <br /> 2 " Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �•' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> J01 J 2CVQN-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 CourftV,,pev lgpment Title;Chapter_9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assesso <br /> WELL Location)1,9;0 Cross Street,- City SS Zip 0-3 Parcel#N'6^ <br /> -/?a /y <br /> PROPEBZY <br /> Owner /P1�!'!A04 G Address 4P/_'W ri_/I� Cit i Zip 7hone# <br /> C-57 Contractor R5/ AddressA& .� 4J/I,� City Zi Li Phone# <br /> Consultant/Sub Cnt;15�W /Je0j,0 �fLAddress�37 G�••e��•.�+. City Lic#� '—Phone# 3Z'�Oi193 <br /> GIS Coordinates:X _'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> OIL BORING# a OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE LV a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS—I/ � TY�'E OF CASING: 0 STEEL 0 PVC a OTHER: <br /> � <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS G It�s1 �' -yew/ <br /> a OTHER: a OTHER APPROX.BORING DEPTH /T a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COND CTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See a r2-o±C4 eSQ^ti Dla/&" <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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> ��JJ ' <br /> Signed x Title/Company /�'/ !s <br /> Print Name QM Gla <br /> r Date I// <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ADDRESS: /�L'y bl. t'LI;Q Ct4,AZ _ <br /> WORK PLAN DATED: bl&C- <br /> {. <br /> Application Accepted By Date Issued 11 Z � Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> - t4— /2-7w SR# ,,S z. <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />