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WELL PEKMIT APPLICATION FORM I <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT I/ <br />ENVIRONMENTAL d For, HEALTH Stockton, CA. 9520 DIVISION , <br />304 E. Weber, <br />(209) 468-3449 <br />NON•REFUNDABLE PERMR EXP►RES 1 YEAR FR M D TE ISSUED application is made in compliance with San <br />�ppllcaGon is hereby made to San Joaquin County fora permit to Construct and/or install the work described. This app Assessor s <br />Joaquin County hereby <br />made <br />SaTitle, Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services, <br />Environmental ss Health Division. <br />Cross Street Giry I v� l� i Zip�— <br />HELL Location f- City, tc K }g,, zjp j 1D (Phone# <br />Address e' <br />PROPERTY Owne. i r C> IC'L �' i l�Le'jZ ZL'�J % 72 "3 l7d <br />Z_5 �S Pnone# <br />Gty �wGiZIP_4 <br />_3t. S - Z ,, <br />C, C-57 Contractor ` 1 `�< 1� > 1 dress r5 L. 3 e# <br />�3.0-3'Sb <br />11 fikHFRrTRLr, AL'r,'l� rLic#5 i Phon� 3 <br />Consultant / Suh Contractor i <br />' <br />-� -I CA: Address i GtHI� <br />Y , Township <br />Gly Coordinates: X <br />WOR TOSE PERFORMED: <br />NEW WELL / BORING ( CPTiGEOPROSE. HYDpOPUNCH, HgrvD-AUGER, DT? <br />SOILBORING# -<_ - <br />Ov- <br />a WELL q Grout Sped' <br />Range r15b0 �, Section <br />„ Q DESTRUCTION <br />e1ow) <br />5 OVER•BORE <br />A TT/4�� a PRESSURE GROUT <br />. 1 <br />-other: r- C 11 <br />COMMENTS: r t? t 1 r �kt ,Sr, h i, I I J e'3 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFtCATlojyIULTIPLE CASINGS? p YES NO WELL CASING DIA: <br />Q MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE�� <br />TYPE OF CASING' (] STEEL � PVC (] OTHER: HOSE <br />EXTRACTION P AIR HAMMER/DRIVSN CASIN07HICKN_SS__ TREMIE TYPE TO BE USED: � AUGERS a <br />p E MUD ROTARY 01 OF GROUT SEAL��- <br />'PUSH POINT GROUT13 SIAL PUMPED: Yes Q No (NOTE: MAXIMUM FREE -PALL DEPTH IS 30' <br />VAPOR ; <br />AIR SPARGE ,Z <br />HAND AUGER GROUT SPECIFICATIONS: <br />SOIL BORING D APPROX, BORING DEPTH i Q BOLTED TRAFFIC BOX or p STOVE PIPE <br />Q OTHER: _ _,0 OTHER__ ---if YES, list specifications here)r <br />CONDUCTOR CASING _PROPOSEO?�­ <br />'COMMENTS* ty s'�, t_I_ 0 ___ l!m C <br />...rc�rrc nnRwGS REQUIRE ACCESS OR ENCR0AL;HMr-l" �cprrTloNs. <br />{rV 1 F•vv• • — <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV <br />certify that I have prepared this application and that <br />the worr wiilSbe a Laws. ii <br />e done in accordance with & Joaquin <br />!hereby Rules and Regulations, and all applicable <br />County Ordinances, <br />a I <br />Title/Company (J _ <br />Signed x t Dato <br />Print Nam j,AC_KI }r S F <br />a DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:_ T— <br />Date lssu®d,-1 <br />Application Accepted Sy Date C - Final Inspection By <br />Grout Inspection Data <br />Oesauotion Inspection By - <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY', AID# <br />RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br />PE CODES <br />,-, C <br />FEE INFd AMOUNT REMITTED CHECK - I C ,> <br />C-57,• WC-WAIVER— <br />C-57 Letter of Authorization to sign permit: En r <br />I <br />r <br />