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ORiGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIGE9,, MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS=EH'D) - UNIT IV <br />304 E. Weber, Third Floor, Stocl��r�,,,_ S95202 p <br />C 0\ o v� S 1 �.. (209) 468-3449 �t M 3: 37 <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />NELL Location Lw �.���; J� Cross Stree_ _ Glty �a� Z Zip Parcel# <br />o ROPERTY OwnerCu,, LZ O Q C-)(_1 Address V t) ZZ City. \� Zip�S��� Phone# a 3 9 { <br />, <br />C-57 Contractor \Vy �� Address \ \��� `��O City�Szipols111IU #� Phone# R�b1 <br />Consultant / Sub Contractor-���c,r & cc VN,,; c_�,Address�`� S � City JLie# — Phone# <br />GIS Coordinates: X Y Township Range Section <br />PERFORMED: <br />CbNEW WELV BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />(I SOIL BORING # (} OVER -BORE <br />I WELL # (] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: y cl�,i� ek �--.) c <br />TYPE OF WELL IN.STAILLATiON TYPE CONSTRUCTION SPECIFICATIONS 5-�-�- �� r`a LPI <br />0 MONITORING I HOLLOW STEM DIA. OF BOREHOLE t0" MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: I <br />EXTRACTION p AIR HAM R/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC. u OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 34?_- TREMIE TYPE TO BE USED: p AUGERS [] HOSE <br />0 AIR SPARGE (I PUSH POINT GROUT SEAL PUMPED0 Ye O No (NOTE: MAXIMUM FREE -FALL DEPT _T5 <br />(} SOIL BORING 0 HAND AUGER. GROUT SPECIFICATIONS: N-?-a--,k <br />0 07HER: 0 OTHER APPROX. BORING DEPTH 5 O'0 BOLTED TRAFFIC BOX r (]STOVEPIPE <br />r CONDUCTOR CASING PROPOSED? <br />'COMMENTS: �3DODrre): <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 1 have prepa <br />County Ordirr",-cks, R61e� jpnd f <br />Signed <br />Print Name K`" IZ A�o <br />this application and that the work will be done in accordance with San Joaquin <br />Mations, and all applicable California State Laws. <br />TitlelCompany W, C),,;,,C),,;,\-Srr ��w ^ CA <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z9O <br />WORK PLAN DATED: 1-17- O 3 <br />Application Accepted By <br />Grout Inspection By liI <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date <br />,�\Z-7-1�"3 <br />Issued ! , 6 Area 1(.116 <br />1 Inspection By �Date LLJ <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />R C'D BY <br />DATE <br />P ST # <br />INVOICE <br />:�d <br />�a6c <br />� r <br />ON <br />,3. <br />0035 <br />C-57--V—WC= WAIVER_ C-57 Letter of Authorization to sign perr?it-Encroachment c._AZZ¢ 9/27/00 <br />EO 39 d X1007.9 HiAIA EEbE89b6OZ 99:ET TOOZ/8Z/ZO <br />• <br />