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RECEVED WELL PERMIT APPLICATION FOKM SITE <br />MITIGATION <br />OCT 0 2 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENV R NIMEN' HEA h 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />P (209) 468-3449 <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 San Joaquin County Public Health Services, Environmental Health Division. <br />(� Assessor's <br />WELL Location Ski)y�hr� tr�G,u� _Cross Street��lhl(�� li� City V-LA.� Zip 7 ZQ Parcel# __LQF—dl� <br />PROPERTY Owner %" AJf S 50&1,J&1u QCn Address3f+� �cutil/Cy L[uR ��R CityS7d�%d�� Zip 4 ZO Phone /�//� �� 3 <br />C-57 Contractor' fcf4 1)V•-iULr• ltrAddress 536 �• WA -r7 �pk CitY r^ZipYSi4 Lic#67 /n1% Phone#l�f�r 3�� <br />Consultant / Sub ContractorADJ t_ kkV,frLxr'/120�llRbddress �7 �ItA� CityS�cY fcl0• Lic# �Z` Phone 14 &6 <br />GIS Coordinates: <br />Y <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HY <br />0 SOIL BORING # <br />0 WELL # <br />Township <br />Range <br />DROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 OVER -BORE <br />_/Id PRESSURE GROUT <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />'COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (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 INSrtU I IUNZJ. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County(O a es, ul sand Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Date <br />Print Name <br />DEPARTMENT USE ONLY <br />.•- <br />Destruction Inspection B <br />COMMENTS/CON <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO I AMOUNT REMITTED CHECK # <br />S U <br />C-57 WC -WAIVER_ C-57 Letter of Auth(, <br />'D QY I DATE I PERMIT / SERut6E42E@ttESfi' --t INVOICE <br />W <br />O <br />to An ermit Encroachment doc 9/27/00 <br />�i <br />