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APPLICATION FM <br />WELL PERMIT A OSITE <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 ORIGINAL <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 />o;r i tir` Assessors <br />WELL Location -310 y s L t � i•) 1 0 1 1' c Cross Street ,T�' Y L' C City �,-6c.L+CV1 Zip 95 aG I Parcel# <br />PROPERTY Owner'C(C �r °� )C4"Address e -'b Q --r Ciiy Zip Phone# <br />C-57 Contractor6p(,c1 ,L r\ S - u Address 15-c ruo City tj � r Ziph3 Lic# �6'L10 Phone# `Q,�--'J <br />Consultant / Sub ContractorAkoitcj !V3 7 Sic, W PS City S t"CJ --6-,I Phone# / (v 7 L` <br />GIS Coordinates: <br />Y <br />Township_ <br />Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />PLSOIL BORING # 0 OVER -BORE <br />` [] 0WELL # PRESSURE GROUT <br />'Other:.3-U - ivy% FT st r c PALJ-7 Grout Specifications: <br />/lnR ARA CNrYQ• <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />PUSH POINT <br />SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA_ OF BOREHOLE Z Sri MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 12 FT TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: Yes p No (NATE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: rC � ""'k, <br />APPROX. BORING DEPTH t,l S F T 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />'COMMENTS_ <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County OF)dinances, Rules and Regulations, and all applicable California State Laws. <br />r <br />Signed x_ <br />Print Name <br />I r r <br />Title/CompanyC nV ro �(�tri to SYc'C a 'S eyc wcz (ec' — <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �!/ 40 -S- �9Z <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />COMMENTS / CONDITION <br />Issued Area�L <br />Date Final Inspection By TTT <br />ACCOUNTING ONLY: AID# <br />I <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / QUEST # <br />INVOICE <br />- <br />2-45'z6- <br />- I- inn <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit c 7/ C- r r "" <br />