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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 />(n) ER 91 GO Mh I A LI <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 tha Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location,/ T N. L-rJi�iu(� Cross Street L j�/r Ci AI Assessor's <br />ty 3`lA''�J'� Zip 9.J L Parcel# <br />-1 2. `. <br />PROPERTY <br />C-57 Contractor <br />y/ralNN(� Address'���z a"9'�i L�i/L City <br />Consultant / Sub Contractor <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING ( CPT <br />Zip !ZfZ Phone# 44VS <br />Lie# 7/7S�)Phone# <br />City- Lic# Phone# f &" -01ea1 <br />Township Range Section <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />(] SOIL BORING # <br />[] WELL# <br />DESTRUCTION (choose type below) <br />��JJfOVER-BORE <br />,4-bu" ]PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: %7`A��� 15T/h%4 /f /r/� /Z- / L <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ,HOLLOW STEM DIA. OF BOREHOLE / V ' MULTIPLE CASINGS?[] YES F]`NO WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS �// �� TYPE OF CASING: [] STEEL ,''PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED: AYes a N/6"tot <br />o` (NOTE: <br />M � IIIJUM FREE -FALL DEPTH IS 30') Z <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS: /0�//1 <br />[] OTHER: [] OTHER APPROX. BORING DEPTH f: [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? �� (if YES, list specifications here): <br />'COMMENTS: GN �f% <Z/ Z %d <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 Ordinances, Ru s and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name ��/ y��5 Date <br />DEPARTMENT USE ON`LY� <br />SITE MAP IN UNIT IV FILE, ADD SS: ���� �• GC �Qtu ( ��1 <br />WORK PLAN DATED: 225 20d) > <br />mac/ <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection B Date 7i <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SE # <br />INVOICE <br />I��� <br />QUEST <br />SD J <br />C-57 ✓� WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit ✓`Encronc me)nt doc -1" 9/27/00 <br />