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SAN J OAQUIN COUNTY SITE <br /> ` ENJNMENTAL HEALTH DEPARTME_ <br /> ' 304 East Weber Avenue, 3r4 Floor, Stockton,CA 95202-2708 UN <br /> (209)468-3449 •Fax:(209)468-3433 Web:www.co.san-joaquin.ca.us/ehd `fa <br /> WELL PERMIT APPLICATION FORM O <br /> IGINAL <br /> r � ['VPv9trVT N <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERI�IT�`SF�I✓� S rH <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 Environmental Health Department <br /> Assessors , <br /> WELL Location 3 5 M�h�ovd Cross Street A,66gSq City SSM b-N Zip 4,SLLs Parcel# Q� <br /> PROPERTY Owners (-mak" Address S My�►�� tkV-a+ ur 1 <br /> City S^o Zip`tS Phone#5LIP lif 3 <br /> C-57 Contractor Cr.� av'tA Address b+X 331• Cityf�IPytI� Zip V514 Lic#W d <br /> aVIPhone#3- <br /> 00 � A"0- 6 <br /> Consultant/Sub Cntr � Address ( Co <br /> City I.3�ldtK Lic# Phone# t-`�' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE-DIAMETER <br /> :( WELL# IKW�N, MW'�lr MvJ-t f, MvJ'ty 0 PRESSURE GROUT <br /> 0*Other Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> lir,40NITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES �rKO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCA TYPE OF CASING: 0 STEEL kP�/C 0 OTHER: <br /> 0 VAPOR . )kMUD ROTARY DEPTH OF GROUT SEAL tSo TREMIE TYPE TO BE USED: ,AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: b,'Sres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: tA,-At,&?r SlJ-n Q~ 1AA'bA%k Cil <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH te -t`t'�' hOOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? O� (if YES,list specifications here): <br /> *COMMENTS: <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin (� <br /> County Ordinances,l IRules and Regulations, and all applicable California State Laws. 1_ _ <br /> Signed x AxV Title/Company 14{m �v11��JO+��� S r- )M j <br /> Print Name Date t 1 ol'm` �l <br /> DEPARTMENT USE ONLY (� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ?i '� S iJ Yl�'r;y�•� �/ n ;'c - <br /> WORK PLAN DATED: (i c halos r 4 21005 <br /> Application Accepted By ��!c tnr r., i Mc'.l r'fn e' Date Issued 1 11 C L.> Area i 4 <br /> Grout Inspection By �� ter; XsADate 3- q Q G Final Inspection By : ate 3 g =Q <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: s t t r - <br /> IVY z .. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT UEST# i INVOICE <br /> jIL15_�_ 11 A F <br /> R# o 0`1" <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit ncroachment doc <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/27/2003 <br />