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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Public Health Services, Environmental Health Division. <br />y� ��, 2�1 Assesso ' <br />WELL Location rDA� " 1Cla Cross Street ►1 L4. City Zi J L Parcel# b --1 <br />C4 1&0 <br />PROPERTY Owner 1C�ot'�4�cY1u 1n�P 4ddss\p �• �2rn. C`ity� as Zipl9�hon /�n� �[J <br />C-57 Contracto,�r . "Z I _� Addres � �1JL J<<+�l Ci yl ' ""-k4ZZiip �ic�5�hone `l v,—js <br />`0� ` ��� �b <br />Consultant / Sub Contractor add"reis�ij W1�Q r� Gih_f�y81�Q. <br />GIS Coordinates: X , Y <br />Township <br />Ran <br />Secti <br />WORK TO BE PERFORMED: <br />EW WELL /BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BqJ� ING # n I Q�� OVER -BORE <br />WELL #YI����-eC t91trLZ 1 PRESSURE GROUT <br />'Other: Grout Specifications: _ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />Gnru <br />>IOLLOW STEM <br />,,VMONITORING <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:—0 OTHER <br />'COMMEN <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES"Q:y0 WELL CASING DIA: <br />CASINGTHICKNESS TYPE OF CASING: 0 STEEL__aq'VC BOTHER: <br />DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: NjYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH _ OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordi ices, Rules an lations, and all applicable California State y Laws. O, <br />Signed x Title/CompanSa'C 7 * <br />Print Name 1 � Date IL 1-�Let� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date IssuedI �--/ IArea LO/ " <br />Grout Inspection By Date 2,71V/0 Z- Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />Gnru <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT ICE RE ST # <br />INVOICE <br />t o <br />RR# 00 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ oachme 9/27/00 <br />