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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468.3449 <br />ON-IMMENNDMLE PERWr EXPIRES 1 YEAR FROM DATE ISS <br />Application Is hereby made to San Joaquin County for a permit to construct and/or install the work desorltmd. This application is made In ace kmae with San <br />Joaquin County Development Title, Chapter 0-1115.9 and the Standards of San Joaquin County Pubic Health Servkes. Envfronmental Health Dhrldon. <br />Asse <br />n <br />WELL Lodon_ ;400 N. F1 Doracb St_ Cross Street Lirrbev Cly 95202 ParoefA <br />907009 <br />PROPERTY Owner- a dTfbXe/F'i reSba1 + Address 250 W. (bl f RD8d city, Zapi&QQM,Phone# 847/931 _?1 <br />CST C.ontradW Address 2365 Wigm IY. Q odd»t 95206 Lic# 512268 P 209AE5-8?12. <br />Consultant/Sub CcntradorChQ7FYRrirrrrr�ta Address esE• 4rir9 sty Inr9 Phone}F / <br />GM Coord'Inat" X , Y Township T1N Range R6E Settlor 20 <br />WGRKTO BE P6RFORIIEa <br />0 NEW WELL I BORWO ( CPT, GEOPROM WDROPUNCH, HAND -AUGER, OTHER-) <br />D SOIL BORING tf <br />ja WELL # V1.1-1 , , & Mri <br />-- <br />DESTRUCTION (choose tylia below) <br />OVER -BORE ; <br />(�] PRESSURE GROU-�J- <br />mp- OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT1206 R 1 <br />MMOINMORING 11 HOLLOW STEM DIA. OF BOREHOLE 8IL MULTIPLE CASINGS? 0 YES )1 NO WELL CASING DIA�-�Z' <br />p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICI(NESS 3/16!' TYPE OF CASING: 0 STEEL )I PVC 0 OTHER <br />0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 17 TREMIE TYPE TO BE USED: 1] AUGERS 0 HOSE � <br />p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes UNo (NOTE: MAXIMUM FREE -FALL DEPTH 1:53(Y) � <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: X11 trust - BMb3rdte <br />0 OTHER: 1'I OTHER APPROX. BORING DEPTH 351 ff 80LTED TRAFFIC BOX or. .13 STOVE PIPE , <br />CONDUCTOR CASIN43 PROPOSED? ( 9 YES. Hat spedfications hare): <br />'COMMENTS: Spemfzmbcris above d=ibe the type of w -Us tD be mrovEd and dnOa-mdby rXE ,M %TxiaM. . <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED I <br />1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, RUIeVind Regulations, and all applicable Calftmia State Laws. <br />Signed z . Tltle/Cornparty+ <br />Print Name— -- M zGv l_ '�'� �tv Cr Date t z/ 4-/n t <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED' <br />Application Accepted By Date Issued Z/�d�� J A D� <br />Grout Inspedon By Date Final Inspection By Date <br />Destrt edlon Inspection By Date 17.12-0 f,11 <br />COMMENTS l CONDITIONS. <br />ACCOUNTING ONLY: AIDII <br />FAM <br />Pg CODES FEE INFO AMOUNT REMITTED CHECK* <br />REC'D BY <br />DATE PERM UEST <br />PIVOIGE <br />la di Doze -2--7q <br />C -57 —W -WAIVER C-57 Letter of Authorization to sign permit n - 9/27/00 <br />