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I' [ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />OCT 2 3 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />,IVic j 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />pi=Ft�;,I7i`�ERVICES (209) 468-3449 <br />WELL PERMIT APPLICATION FuRM <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />Assessor's <br />WELL Location `C�p �0 1 t 0 � `IJItJO __Cross Street r �I � City �,IA Zip_ x`11 Parcel# ZZI -O �i O <br />PROPERTY Ownet?VN, �V� Q�l�.� Address �,� An, 6o&_ CityZjp_gL4 C_Phone#_:'z 3 �t 310 <br />C-57 Contractor W!2.SL �'1A� �tn�'� Address Z EA �~ Cityp�17�{L Lid# i�Phone#� ZL% 6 <br />Consultant/ Sub Contractor Address S City S�bLic#.{uZPhone# �{ (off -� DO (o <br />GIS Coordinates: <br />Y <br />Townshi <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />kN. W WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) 1� <br />0 SOIL BORING # [] OVER -BORE � <br />�NVELL # K4_) -(9[I PRESSURE GROUT <br />"Other:__ Grout Specifications: — <br />COMMENTS: <br />CATIONS <br />TYPE E WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSO <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE_ MULTIPLE CASINGS? YES NO WELL CASING DIA: <br />0 EXTRACTION I] AIR HAMMERIDRIVEN CASING THICKNESS_ TYPE OF CASING: [] STEEL PVC OTHER: ` 7� <br />[] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: •)AUGERS 0 HOSE <br />p AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: 0 Yes &No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')-1 <br />0 SOIL BORING 1] HAND AUGER <br />0 OTHER: [] OTHER <br />'COMMENTS: <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH SO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PRCPOSED?_ A) t)) (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 Orc}illarlf;esf-,2ules and Regulations, and all applicable California State Laws. <br />r_ <br />Signed <br />Print Name ! P. 0 l <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />I <br />Application Accepted By �/i�^ ���s�� - Date Issued Area <br />Grout Inspection By { I �� Date O Final Inspection By �tn�nC� Date t0� OIO/ <br />Destruction Inspection By Date <br />r_uucklTo ! 1rnWnmrlfjco <br />v <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />]DATE <br />PERM FT REQUEST # <br />INVOICE <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit chment doc 9/27/00 <br />