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�- WELL PERMIT APPLICATION FORM SITE <br />UjC�, =- MITIGATION <br />SAN JOAQUIN COUNTY UNIT IV <br />n- ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />0-' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />C--, (209) 468-3449 <br />t. ] NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />nJ <br />Application is h®by 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 />j� Assessor's <br />WELL Location j,� ((WrOkele t all N- CrossStreetei �%lvl City /(>,) Zip y�Parcel#&W—/ LL9 of <br />PROPERTY Owner �M i PGh 9/C Address �s i JUL(; �ln�; ✓JY . City ��G'� Zip T%oj Phone# G VH <br />C-57 Contractor Je GLIR,A,Address 763 OA -,f L I C�' CityI`�✓� 61V Zip q514)-Lic#��hone# )63r -l/t f <br />Consultant / Sub Cntr .A6- Address �(,? 7 S f" (.' �� City Lic# 6b�1J,�-2 7 Phone# Lel 7 /0 0 6 <br />GIS Coordinates: X Y Township Range Section <br />WOFX TO BE PERFORMED: <br />EW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />OS <br />IL BORING # 0 OVER -BORE <br />B�WELL # 0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE._' MULTIPLE CASINGS? a MULTI-LEVEL? 0 WELL CASING DIA: -� <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS( L TYPE OF CASING: 0 STEEL PGC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 70' q& i% TREMIE TYPE TO BE USED: .AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 8,0o (NOTE: M/ MUM FREE -FALL DEPTH IS 30') i <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: LI I �7 ('U t� 10�� Jy Ii& ? S H;i—L" <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 1N>' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />*COMMENTS: 4- 1�V L A/1 (/L) <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 Ordinancgsb Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company_>t'y <br />n <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />0)l <br />WORK PLAN DATED: / <br />Application Accepted By �> ��( Date Issued 1 �-/ f e 10— Z_ Areb O <br />Grout Inspection By n..(Sn Date Final Inspection By Date r Z 7-0 b <br />Destruction Inspection By Date / <br />COMMENTS / CONDITIONS: -t, <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />I FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P REQUEST # <br />INVOICE <br />77 z <br />14-r-2-11 <br />o izo�. � �... <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ nc r�tent doe_ 8/29/02 <br />