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• <br />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 />Assessor's <br />WELLLocation %fib �h Cross Street C . ((City I ZipC[S2.OZ Parcel# 13CT-()S'y=" <br />PROPERTYOwner UAa jle& � Address -70(x, N f:L 11_;o;cl o City5 i'" Zipot (;-2j) ZPhone# 24gcf-Y�5— 2-667 <br />Gln Addressl�ip�LV Lic#�2z�hone#(4�V—If`f3 <br />3C-57 ConVactorktnV�ti)t,�tyin <br />Consultant I Sub Contractor ddress 6)-� L t/l,; CityiQ/c Lic# (o ZZ Phone# ZC)Cf - (f 6%— (006, <br />GIS Coordinates: X <br />N <br />WORK TO BE PERFORMED: <br />1jkNEW WELL / BORING ( CPT, EOPROBE YDROPUNCH <br />X SOIL BORING #_ <br />0 WELL # <br />'Other: <br />COMMENTS: <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 />�KUSH "POINT <br />.&SOIL BORING 0 HAND AUGER <br />0 OTHER:_0 OTHER <br />'COMMENTS: ) s- c <br />Township Range <br />HAND -AUGER, OTHER-) <br />Grout Specifications: <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE O <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Zig MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: VA <br />CASING THICKNESS A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS -p-HOSE <br />GROUT SEAL P'j;,1FLL). "� Yens 0 No (NOTE: MAXIMUM FREE -FALL. DEPTH IS 30') <br />GROUT SPECIFICATIONS:PUt,,, (,4A �e . 1 �T <br />APPROX. BORING DEPTH (on BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASIrp 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 Orcft9arkcesnRules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITIONS: <br />Title/Company a4 U I A ) Lk CL <br />Date C( I - C, / I <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Issued <br />0( - <br />Inspection By <br />V2 oo/ <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />-:1 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />R C' Y <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />CS R#06L Z <br />C-57 WC -WAIVER C-57 Letter of AuthoWzd b o sign permit_ n en oc 9/27/00 <br />G <br />