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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Environmental Health Department. <br />Assessor's <br />Parcel# d <br />ZWELL LocationJ�"14&- 4V. Cross Street Citys7,064i_041 Zip 24 `/G/()7 <br />PROPERTY Owner SUS euWIdl Address CL.City!oZip�7 <br />Phone Z=S! <br />C-57 Contractor (TWafiL /'0 a%LilA Addres&53t,, SVLvA77- AV(_, r��C, ity�i_. Zip Lic#twin � 2 Phone///( �� <br />Consultant / Sub Cntr `�, - (�i • 4� _ Address 3 7 Sd Alm Kr/. city -< a Lic# �UZ2 7 Phone# 414 7-1 d 0� <br />GIS Coordinates: X , Y , Township Range Secti <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OT *) C,�I�`Z 0 DESTRUCTION (choose type below) �1 <br />0 SOIL BORING # �� 0 OVER -BORE <br />0 WELL # II. w - ' �'� 0 PRESSURE GROUT �� <br />`Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />'COMM <br />CONSTRUCTION SPECIFICATIONS i, <br />DIA. OF BOREHOLE � MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />CASING THICKNESSS( �4 �b TYPE OF CASING: 0 STEEL KPVC 0 OTHER: <br />DEPTH OF GROUT SEAL V[AjZjau,) TREMIE TYPE TO BE USED: XAUGERS 0 HOSE C� <br />GROUT SEAL PUMPED:Ye 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: L <br />APPROX. BORING DEPTH i OLTED RAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 0, ( if YES, list specifications here): <br />zti /--& - AC) W <br />NOTE: OFFSI-rE'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 prep red this application and that the work will be done in accordance with San Joaquin <br />County ()rdi a e5, -Rules and Regulations, and all applicable California State Laws. ,, i <br />Signed x Title/CompanyS r (2 Uhf 2_04ikQ 1� � �✓� //�i�it�Ci1 L <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />3535 6• <br />WORK PLAN DATED: 2--t2, -o Z <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />-Z 9­�o <br />Inspection <br />r <br />Area D� <br />■r Date / - G _O 3 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />R 'D BY <br />DATE PERMIT EQUEST # <br />INVOICE <br />�/• a <br />C-57_ WC= WAIVER C-57 Letter of Authorization to sign permit Encroach rfiefff -doc 8/29/02 <br />