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tlx) <br />tP) <br />WELL PERMIT APPLICATION ARM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. WebOr, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <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 '3S-09P J\.‘.) ine Cross Street 114AkiictlAGVt City (kait-i-t)et Zlp C/5-40j Parcel# jof -03/9 -03 <br />PROPERTY Owner Ilb‘pr# uk_wet voaddresss-s37 THor,(614.1--ikcity zip954.1. Phone# ,?.cf? y - k 77A <br />C-57 ContractoN ‘16 rvik_kk Address ft) BO City 94.7)Okk Zip*-7/ Lic#1410 Phone# '9/V777-II/0D <br />Consultant / Sub Contract4 (4/1(714 a -CT V • Address 6)--coi CItycthieyla. Villticit Phone# (S7) Arl <br />GIS Coordinates: X , Y <br /> <br />Township <br /> <br />Range <br /> <br />Section <br /> <br />WORK TO BE PERFORMED: <br />a NEW WELL [BORING ( CPT GEOPROBE, <br />t <br />HYDRONNi 91-1,.FIA,ND-AQGER, OTHER') <br />.SOIL BORING # CFI ThlUkSIA <br />WELL # <br />'Other: , Grout Specificflons: <br />COMM-ENTS: .-t e ‘ (.:14'1 S at 17D114tel RP C-1 t 4 (kJ j-0-64--N----+ Jr) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES y'40 WELL CASING DIA: <br />CASING THICKNESS i\.)/ / TYPE OF CASING: 0 STEEL a PVC OTHER: <br />DEPTH OF GROUT SEAL /5- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOS" <br />GROUT SEAL PUMPED: a Yes po Ng: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Dy V" 6,44/J-67/kJ C44 <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Ai ( if YES, list specifications here): <br />"COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />['DESTRUCTION (choose type below) <br />0 OVER-BORE <br />g PRESSURE GROUT <br />aiayt'L <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />LI AIR SPARGE 0 PUSH POINT <br />)1LSOIL BORING 0 HAND AUGER <br />0 OTHER: ,toTHEF0e0f1 <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 0 inances, ules and Regulations,and all applicable California State Law <br />0 evi) ai Title/Company OefeDr51— (4( pweelia., 4,A)tuu <br />Print Nam <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued (a/ <br />Grout Inspection By Date Final Inspection By <br />Destruction inspection By Date <br />0 Area R-tV 4Cg <br />Date <br /> <br />COMMENTS /CONDITIONS at (.) :EAD tses <br /> <br />Signed x <br />q-n-e ate ( D CI 3 /n0 5 <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AID# EACit <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT IS QUEST # INVOICE <br />y - ‘4° 7; 4. 4 13/ /•)/ M T sR# <br />C-5 I <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit c <br /> <br />9/27/00 <br /> <br />elOOld HidId <br /> <br />EEt,E89b62Z St,:OT 00E/8T/OT