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-WAIVER WC <br />LAJIVINICN I o t ‘..vrtiali ,........,. <br />ACCOUNTING ONLY: AID# FAC# _• . <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE LIVIIX--/ SElinag_fEQUEST # INVOICE <br />' - ..."2/1)4 0 /-46"kri-- ,S Mt <br />. - , 77--------, <br />SR# - '- ' ` <br />- • • • n in -7 inn <br />C-57 C-57 Letter of Authorization to sign permit achmeni aoc <br />Area <br />Date <br />Date <br />Application Accepted By A-) <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />Final Inspection By Date <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <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 />Assessor's , ?t• <br />WELL Location / y-,33 Cross Street Vo•-i•-eli'de- City Zip '5/ Parcei# r <br />PROPERTY Owner cc ri_4;,) Address / 3 I-5/ City Zip 753 Phone# '7//1 2-3`)'/5?3 Le <br />C-57 Contractor Address 9,5c. 125 -5/3 P/1.111."5 City iii-e/-0-)-<•Z Zip Y53.) Lic# Phone# <br />Consultant/Sub Contractor 446c,,,,,, „lc-bey-74—z_ 1:4,,c)-4,6 Address 2-c5' •'•-) City Lic# Phone# 2.2 5 `I/ <br />GIS Coordinates: X , Y , Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a SOIL BORING # i 7 <br />fl WELL # <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />Grout Specifications: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />Q MONITORING 0 HOLLOW STEM <br /> <br />EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR flMUDROTARY <br /> <br />0 AIR SPARGE A-PUSH POINT <br /> <br />NcSOIL BORING a HAND AUGER <br />OTHER: fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES [LNO WELL CASING DIA: <br />CASING THICKNESS A) 'TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEALfc-t-,- I -,--tk TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: ,KYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: A-Li-cS--- c--.7 -->"-/- <br />APPROX. BORING DEPTH /it) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A,l, , ( if YES, list specifications here): <br /> <br />*COMMENTS: <br /> <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 Ordinances Ru s and ulations, and all applicable California State Laws. <br />Signed x Title/Companee231/47.2r /77a2c7jey- _6/.67:, Re/4 , <br />Print NameC,..."51"/".:_/21 re,' Date a/ Z40/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: )„2.. I — <br />c;2-t:)i L <br />