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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202G11 r ; -:, ,. g: S7 <br />(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 />0GCJ (-/ f j'"3- Assessor's <br />WELLLocationZZOlJV IQkSSOV) Cross Street -5 City. LX�Zips Parcel# Z39 -0&0 --SCD <br />PROPERTY Owner Ck✓✓L✓1 PjiOCU(jS (7Address, 0. 15U)(U00('/ COD <br />✓1 �wUiKip 74V[5`:L� <br />j Phone#(q?T C0'1 -/Z -%S <br />�22��� l�11 o _)'Wit(g1(J)(J3ff <br />C-57 Contractor C���� Or /) Addres&. 63Z VIS (-, 0./(& ity u c v Zi{��y JZLic# Phone# <br />Consultant / Sub Contractor_ <br />GIS Coordinates: X <br />nl <br />Y Township Range Section <br />(ql (s) 9G I-C3l CU <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />a SOIL BORING # 0 OVER -BORE <br />p, WELL # a PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />(I MONITORING <br />0 HOLLOW STEM <br />Q EXTRACTION <br />a AIR HAMMERIDRIVEN <br />Q VAPOR <br />MUD ROTARY <br />AIR SPARGE <br />Q PUSH POINT <br />(I SOIL BORING <br />HAND AUGER <br />OTHER:_a <br />OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS ]'[ <br />DIA. OF BOREHOLE— MULTIPLE CASINGS? 0 YES I NO WELL CASING DIA: C- " �Q ` <br />CASING THICKNESS_'l H L/ C TYPE OF CASING: Q STEEL ® PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ® AUGERS 0 HOSE <br />GROUT SEAL PUMPED: I Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') S <br />GROUT SPECIFICATIONS: ru& 4 0v,i-oy_-4 <br />APPROX. BORING DEPTH ZS' . u 0 i !2)5l BOLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED? �1 D ( 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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California <br />State Laws. <br />CIL <br />Signedx Title/Company J l\-1 1�� <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS:, <br />WORK PLAN DATED: /0— <br />Application <br />0" <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Z <br />Date <br />N <br />Issued— <br />Inspection By <br />--mi <br />ACCOUNTING ONLY: AID# reale <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERM E REQUEST # <br />INVOICE <br />C -57 —L WC / -WAIVER C-57 Letter of Authorization to sign permit—'4LI Encroachment dox,.464r 9/27/00 <br />