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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 />SITE <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 Sar�I H <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services, Environmental Hai t Division. ;GES <br />Asse§� <br />NELL Location , �J C S ;<��p� 1 Q- Cmss Street w 1 Z City Zip Z d Parcel# <br />DROPERTY Owner LA, LS(_ -ALL. Address �O �n �` C a�� City s "\1 ' ZipclS 3"Phone4g g " I <br />C-57 Contractor Coq+��iAddressGs�� e \� C4e^e2 Zip �SSj l� <br />Lic# �S�bS Phone# 1 a S 3] 3 SW <br />Consultant Sub Contractor-�10� , Cc� �<< �t`1 Address \� 1� Sh _City J Sfi� Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />(] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />(� SOIL BORING # S t3 v S l3 >- (] OVER -BORE <br />C-1[] WELL # [] <br />� " PRESSURE GROUT <br />"Other: <br />Grout Speclfications� <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />[] MONITORING <br />11 HOLLOW STEM <br />DIA. OF BOREHOLE <br />MULTIPLE CASINGS? I]YES ONO WELL CASING DIA: <br />EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />CASING THICKNESS <br />TYPE- OF CASING: O STEEL D PVC []OTHER: <br />[] VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: []AUGERS a HOSE <br />AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes <br />(] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />-------------------- <br />'j SOIL BORING <br />a HAND AUGER. <br />GROUT SPECIFICATIONS: <br />-- -------- <br />(] OTHER: <br />(] OTHER <br />APPROX, BORING DEPTH <br />(] BOLTED TRAFFIC BOX or (] STOVE PIPE <br />CnNnUCTOR CASING PROPOSER? — (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 Ordinances, Rules angulations, and all applicable California State Laws. <br />r <br />Signed x /'/ ! TitlelCompany <br />6 <br />Print Name 61%/ PL•�p1' Date ?/ 2��r1 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />C7 <br />Application Accepted By I Date Issued I i _Area <br />Grout Inspection By Date Vs-lci Vs—lcFinal Inspection By I� Date 5 P <br />Destruction Inspection By Date % <br />COMMENTS I CONDITIONS: VL S S ✓; �r <br />ACCOUNTING ONLY: AID; <br />PE CODES <br />FEE INFO <br />I AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE EST # I INVOICE <br />03 S <br />C-57^ WC; WAIVER_ C-57 Letter of Authorization to sign 9/27/vu <br />E6 ?C�'d cI00-!� Hl�I� EEbE88b6aZ 9S:CT T9CZ/8Z/Z© <br />