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WELL PERMIT APPLICATION ARM <br />�U- _ SITE <br />4 <br />MITIGATION <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />CV <br />.e — 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />u w (209) 468-3449 <br />�157.7- (Z:) <br />N <br />Q 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 />f Assessor's <br />WELL Location ALe►`Zicey_ L&o_A? Cross Street qe. aiL St City y/ �-U�,Y , Zip aParcel# &13-I?o -J� <br />PROPERTY Owner{� Address 0U c City to 1, ZipyS) y/ Phone# �3-Y) <br />C-57 Contractor 1;r5(06&tUf% If/ ddress 7 5J- /+e C 1�, City r�7 BVI ZiPPY Lir %!�S/(phone#N& 3� r( <br />Consultant / Sub Cntr 7 Address pj� S �,(,�J 2c City & , Lic#J(� �Phone# <br />GIS Coordinates: X <br />IL <br />Township <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />WELL # <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />PtONITORING I)OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: ;>,1 <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: Z <br />CASING THICKNESS_I;U41 'I l% TYPE OF CASING: 0 STEEL J�PVC 0 OTHER: <br />DEPTH OF GROUT SEAL -Q-0' TREMIE TYPE TO BE USED: J�KUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes A�No (F;OTE: M IMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: °14 i � ttrf l a c/ 4-G (-' Io <br />APPROX. BORING DEPTH,' O ' f I,} tJ ` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /KL <br />i- I)✓) -=C ) ,3-0 l7A)1_ I I -e <br />( 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin nces, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 6e() h ( 5 ) <br />Print Name ; , ,� /trt C�� Date f.� / U/ d <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By,/,��,�p�( i / Date Issued Area P 0 <br />LI <br />Grout Inspection By Date 12 ' 0/ D Z --Final Inspection By /t Date/ 2�1 Z4 OZ <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: LU L%) <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P UEST # <br />INVOICE <br />L��eE, <br />oo <br />!-?-77/ <br />4 <br />C oz <br />A- <br />C-57 WC ' -WAIVER' C-57 Letter of Authorization to sign permit Encroim+ient-d—oc — 8/29/02 <br />