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WELL PERMIT APPLICATION FORM <br />FEB 1 9 E200�3SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRO�!MEN IIiN,X/IR LT PNMENTAL HEALTH DIVISION (PHS-EHD <br />PER�.�IT%SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />Vtw `-,$ 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 />I� <br />1 Assessor's <br />WELL Location ^ W 2X1 AJCA.rf- Cross Street 1l� ^�� ^ S City Sb° �� Z AIS ZoZ Parcel#1-3-1--31--3 <br />PROPERTY Owner -J°)00~ "-10FmA k-kl <br />��Address IIC''k/ �t�City ° ��� Zip95�Z Phone#IL <br />����nn <br />C-57 ContractorOtL�7 �'� �'�^� Address S �G�` + v1 AX %-'c.. CitySG��1-ZipQSU�- ZLic#1 4�4LBePhone4409 - V30 -6'"a <br />�yL S-216 <br />Consultant/ Sub Contractor0k'g01'` (D�P Ste'"�1 Ahdress�c12) koll4n}v Puk—, CityI, <br />C4Scn�� Lic# _ Phone#9ZS-iZG-Zf0-7 <br />D <br />GIS Coordinates: X 37o S1 / 07 P Y `Z\ 17 52 \.J , Township I'0 Range (-,E Section ) O <br />WORK TO BE PERFORMED: <br />(ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />O SOIL BORING # <br />O WELL # MW- Xb <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />I MONITORING <br />9 HOLLOW STEM <br />O EXTRACTION <br />O AIR HAMMER/DRIVEN <br />O VAPOR <br />O MUD ROTARY <br />O AIR SPARGE <br />O PUSH POINT <br />O SOIL BORING <br />O HAND AUGER <br />O DESTRUCTION (choose type below) <br />O OVER -BORE <br />O PRESSURE GROUT <br />GROUT SPECIFICATION <br />CONSTRUCTION SPECIFICATIONSz IIIDIA. OF BOREHOLE 6 )I MULTIPLE CASINGS? 0YES Q NO WELL CASING DIA: <br />CASING THICKNESSSc."iL U9 TYPE OF CASING: [] STEEL *PVC O OTHER: <br />DEPTH OF GROUT SEAL 0-10' TREMIE TYPE TO BE USED: p AUGERS OHOSE <br />GROUT SEAL PUMPED: <br />GROUT SPECIFICATION <br />O OTHER:_O OTHER APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? 0 ( if YES, list specifications here): <br />O Yes (j No <br />11C Caw4 <br />2St <br />(NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />It <br />N BOLTED TRAFFIC BOX or O STOVE PIPE <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br />* CALL THE UNITry ITOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />a <br />Rinnrl x NSP 1 Title/Company_ PR��tcb Enu R�nnc.�b 1 C�.,S.II�. <br />Print Name+', �^'`+_�`ov� t Date Z 1 t o /03 <br />SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />�J /1 nFPARTMENT USE ONLY <br />Application Accepted I <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br />Date Issued _S t <br />Final Inspection By <br />Area <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P T # <br />INVOICE <br />2 0"'� <br />Z�� <br />;�;M,jyX13 <br />2� 2 <br />C-57_ WC/WAIVER_ C-57 Letter of Authorizc,14ono s n permit E'rrcroa,&htent-doc_"7/17/00 <br />