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_nECE vpnn <br /> J. ` 142010 <br /> oP4"t" SAN JOAQUIN COUNTY ENVIRUIVIVILNTHEALT�� <br /> -- <br /> ENVIRONMENTAL HEALTH DEPARTMEWR IT/SERVICES <br /> z.�- �-,..•,��.,y SITE <br /> .. <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNIT I1/ <br /> ;... <br /> F� ORi <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 wills San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin Count Environmental Health Department. <br /> SCA_s � V_lb —S: �_R.S%-� Assessor's <br /> Well Location 4 j0 k G.}h,,�keylCross Strep C.,)gA L6W<'nt City S-NTQ Parcel#k'�k\~C7 h 4022, <br /> Property <br /> IN <br /> Owner_ �c\� <br /> ovy Lic df$IQPhone#19'.SC� . Phone <br /> d1C-57 Contractor—Nle-'A&SM�� "Address3�hS 9y <br /> ConsultanUSub Cntr S' S Address—?i City Lic# Phonek, 5 _ U <br /> NIS COordinWs:X Y TownshipRange- Sty Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELLISORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BURfIt El OVER-BORE DIAMETER <br /> 6(WELL# 1 ❑PRESSURE GROUT <br /> I�L'OTHERaGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL A: <br /> b/ <br /> WELL CASING DI <br /> ElEXTRACTION C1 AIR HAMMER/DRIVEN CASING THICKNESS S C-\ TYPE OF CASING:El STEEL bPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL ye_r-"�TREMIE TYPE TO BE USED AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes V. (NOTE:MAXIMUM FREE-/FALL D PTAH"ISS 361) <br /> ❑SOIL BORING L]HAND AUGER GROUT SPECIFICATIONS rG@Tc•���/d1 notr�aw [:HM�iYrs <br /> [I OTHER: [I OTHER: APPROX oL BORING DEPTH 5 ` ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (If YES•list spectricatrons In comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 4 / 'ORKI OURS NOTICE REQUIRED FOR INSPECTIONS <br /> f i <br /> I hereby certify t 1 I hav11 pre ed t Isapplic ion d that tho work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, dzll apyl11.t3 a alif rn'la Law ./ I <br /> Signed , :• !/ Title/Company <br /> Print Name;���i�.� � - f�i () lr��'"' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1�7 1A 11, 04DI& <br /> WORK PLAN DATED: Leovv6a n.�a4 81'-s014 <br /> I14 <br /> APPLICATION ACCEPTED B DAT ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE -� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> -L tot gGt. `av LS�kJ 1 ts�cJ SR#OoSgl o <br /> C-57 WC f -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />