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ORIGINAL <br />WELL, PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERY'ICES UNIT IV <br />Cl' ";;'° - tN'VIWW6AENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 9502 <br />(209) 488-3449 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE iS UED <br />,pplication is hereby <br />Develo <br />pment ent T tl Joaquin <br />County for a <br />3 and the permit Stands construct <br />of SanJJoaquan County Pll the work ublic Health S rviescribed, I is cesl �tnononmeis ntal Heath e in IDivision. ith San <br />oaquin County P / Assessor's <br />G.; ✓e, �k Zi Parcel#_ <br />VELL Location s�. �L � U✓'w.�j Cross Street 1�(tic�c �� itY rp <br />: C Sfi�ty z1ip# <br />7�t.G�rCPhhoennee#r�J �Z <br />Vj <br />• –0�fl -7 <br />)ROPERTY Ower_ e -s kAddress_—yp–?'7�1� <br />G7 QjdCQG/ZlyID Lslt l[V <br />13'v2_t; <br />t''� tyS�cTRuc75_F'F,�,,��► u_ _ l -??Z <br />;onsultant / Sub Contra ctor ' <br />Address �6)c <br />,, Torrnefiip <br />RanCte�'— ection <br />;i:; i:nnrolnates::n -- <br />/YORK TO BE PERFORMED: r y nl CACI; OTHER" <br />111 +P! VVtLL! BQFzIW'; j {:P .SOIL 13 RIN l 11 �'+iitiil'I INtil {, HI�,EiQ �� <br />( _ p SOIL BORING V <br />rHELL # <br />' Grout Specifications <br />`Other:_ —_-. <br />COMMENTS: _ • <br />TYPE_ OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />'–$HOLLOW STEM <br />[] EXTRACTION <br />n AIR HAMMERJDRIVEN <br />p VAPOR <br />q MUD ROTARY <br />[] AIR SPARGE <br />p PUSH POINT <br />[] SOIL BORING <br />p HAND AUGER <br />[] OTHER -.___0 <br />OTHER <br />`COMM <br />DIA. OF BQREHQLE f3 � � MULTIPLE CASING <br />CASING THICKNESS 5i-4yell TYPE OF CAST <br />DEPTH OF GROUT SEAL ZY" TREMIE <br />GROUT SEAL PUMPED:*Yes n No (NOTE: I <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />mn-rF- f1FFSITF BORINGS REQUIRE ACCESS OR ENC <br />d nM9TRUGT1QN (':hoose type below <br />Ii Dor-!C <br />p PRESSURE GROUT <br />N <br />�? O YES `ANO WELL CASING DIA: Z <br />G: R STEEL -{�[15VC 0 OTHER:_ <br />1 PE TO BE US(E'_D. Q AUGERS XHOSE <br />9AXIMUM FREE -FALL DEPTH IS 30') <br />TED TRAFFIC BOX or p STOVE PIPE <br />i, iist specifications here): -- <br />MENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR A�L. Kr_WU1rt=1J r""` <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />ces, ules and Regulations, and all applicable California State Laws. <br />/ <br />II,County OrIna. y TitieiCompany �✓� <br />Signed xV''Z <br />–r-- n�ro Li' ti <br />Print Name —CTV <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />/LS s Eo <br />WORK PLAN DATED: Z '/ 0 2-- - <br />Date Issued <br />Application Accepted By_ Final Inspection By ` <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY: A!D# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PEMIT 1 SE O 1? EST # <br />` <br />C-57_ WC____ WAIVER C-57 Letter of Authorization to sign permit ncrcachment doc <br />�Tl <br />.r <br />O <br />X <br />_ &- 1 <br />7•Z(" -DZ. <br />INVOICE <br />9/27/00 <br />