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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 Cqunty Environmental Health Department. <br />�` '4 6Z f L %C 1 41-2 Assessors <br />WELL Location 375 W• / 1)ZELTQ^/ Cross Street SCg f F S+A}city S�rOLK rpn Zip '152 Qb Parcel# <br />PROPERTY <br />S L..1440—,Address_ �3%5 6j, 8 0) Z r�.City S Tor. K rt -N Zip -529 Phone# h 0(j 7 • % % %� <br />AVL. No <br />C-57 Contractor g75Lic5a <br />mxj , y p <br />Phone# <br />Consultant /Sub Cntr-h . Address 507 S 4A �-, R Q City • Tot ic# Phone#(2r 9 6 7 0 p <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) B DESTRUCTION (choose type below) <br />B SOIL B# B OVER -BORE. DIAMETER <br />'WELL #n V�J k S •. �� B PRESSURE GROUT <br />'ELL <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />SfS AT�LwtQ V n C% IMA o�1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y ;If <br />B MONITORING HOLLOW STEM DIA. OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: G <br />scheev j c <br />BEXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS L/0 TYPE OF CASING: B STEEL -kVC B OTHER: <br />�,�t.•V POR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS B HOSE <br />IR SPARGE/ OZONE B PUSH POINT (GP or CPT)GROUT SEAL PUMPED: B Yes o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />5 B OIL BORING B HAND AUGER GROUT SPECIFICATIONS X- <br />B OTHER:_a OTHER APPROX. BORING DEPTH 3 S' BOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED .n (if YES, list specifications in comment section; <br />COMMENTS: <br />NOTE: OFFSITE SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT r ERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County qEQnances, Ru5mi-fnd Rg9L lations, and all applicable CaliforniaAtate Laws. i <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Title/Company 141 , c <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued13/d � Areag' ' / /� <br />Grout Inspection By Date S / 3 L0 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / ST # <br />INVOICE <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ ncroa c 9/30/02 <br />