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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED <br />Application is hereby made to San Joaquin Coun y for a permit to wristruct and/or install the work described. This appicatlon is r jade in o=pliance with Sar, <br />:oaquin County Development i Itle, Chapter S-1116.3 and the Standards of San Joaquin County Punk Health Services, Enviror rental Healh Division. <br />~1 `�Assessors <br />WELL Location' I v'1; A-1 DA -101 S I?Ogj Cross Street � City O t 2'p��j_Parcel# <br />PROPERTY Ow -ter&_ IIIF �Mt Address81o0 !.. D�C �cI Gty�Zlp ZDV Phone?* 4l!- I bl�l <br />C�7 Contraccr�LOA IAI Adcress IM � f3 CK,- i Cly cA1 Zoo_' I L:c�l. 7iC4P^ones'( )" _I-41(ii' <br />Consultant Sub Contractor Cyn,- l 2e1 �Address]]1y Y1Artllll S�CCJt''� Cit k Lich Phcne� <br />GIS Coorcinates: X_.... , Y <br />Township <br />Range Secllcr <br />WORK TO BE PERFORMED- <br />n MEM WEt_I_ t FCRIMC (CP-, GEOPP.OE'E, HYDROPUNCH, i -AND -AUGER, OTHER-) >5 ESTRUCTiCN (c`.ocse tyre below) <br />L <br />0 SOIL BORING tt 0 OVER -SORE <br />YELL k Vy%lAj 1 '111RESSURE GROUT <br />'Other. Grout Specifications:AlA f ey"k <br />COMhENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />A0NITCRING 0 iOLLCW STEM DIA. OF BOREHOLE_ MULTIPLE CAS NGS',0 YES ONO VI ELL CASING DIA: Ztr <br />0 EXTRACTION r, .AIR HANIMER'DRIV=N CASING THICKNESS Sr In 4f) TYPE OF CASING O STE=L ,)'PVC 0 OTH_R: <br />B VAPOR 0 BAUD ROTARY DEPTH OF GRC'JT SEAL 2-)— TREVIE'Y:E TO BE USED' 0 AUGERS 0 H:1SE <br />0 AIR SPARGE 0 =JSH POINT GP.o'JT SEAL PLIVPED: 0 Yes a No (NOTE. MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGcR GROJ7 SPECIFICATIONS: <br />0 OTF-ER: LI CTHER A=PRCX. BORING DEPTH tl5 ' �(?OLTEC TRAFFIC BCX or p STOV= PIPE <br />��11 <br />CONDUCTOR CASING PROPOSED? ( f YS3, lis: spec.ticaticns here). _ <br />•CCS!,YENT5 SEL' U.*I ( (r`l�. ioc &ACjLi I, <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 Ord- ance , es and Regulations, and all applicable CaliforniaQ State Laws. p <br />Signed x Tite/Ccmpany J7Gt iL f/ -;p -n [ C t 5 /CIJTyCI tip Sf S <br />Print Narn1 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Crout Inspection By hl. Date <br />Destruction ;rcoecticn By Date <br />COMMENTS I CONDITIONS. ' <br />ACCOUNTING ONLY: I AID# <br />Issued [ L Area <br />I Inspe=lon By Dale <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECKS I RECD BY I DATE <br />3sCcoil l �r�� �� C1 I( R#C©� �6 5©L; <br />Mrwriirn r G" 1 ..�♦.,j. ,,f 4u41,,u;iu.+irr. + 4 Gn�..,..,.1......n+ .1.. - <br />INVOICE <br />Q!^.-7 1x11 <br />00 <br />