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GIS Coordinates: X , Y Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />fl SOIL BORING # <br />*WELL # P10E1140 14.11„3'01) <br /> Grout Specifications: iNSLZA <br />COMMENTS: COMMENTS: <br />*Other: <br />O DESTRUCTION (choose type below) <br />gOVER-BORE <br />a PRESSURE GROUT <br />SITE <br />MITIGATION <br />UNIT IV <br />Print Name Date <br />Date <br />Date <br />Date Issued <br />Final Inspecti <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS, CONDITIONS. <br />66,e' <br />REC'D BY DATE <br />ed0Old CO 39Vd CCPC89P6O7 TC:CT 000Z/120/7T <br />PE CODES FEE INFO AMOUNT REMITTED <br />INVOICE PERMIT / SERVICE REQUEST # CHECK # <br />a 30 t u) Ckzt We/a-725 'S'et SR# 10 ;54-6 F-- - <br />-WAIVER C-57 Letter of Authorization to sign permit 9/27/00 <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 Or,Lanc es and Regulations, and all applicable California State Laws. <br />Signed x Title/Company frdeN 74-P-0-:\ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Ho- 2-- <br />DEPARTMENT USE ONLY <br />64'33 <br />ay-fit"7( <br />alq/n3 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />C-57 WC <br />ORIGINAL <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 />WELL Location (0(ifn A1/4 Ve..— Cross Street City 1-0CV...6n Zip 9c2.61 PAasr:ls#8641 tO <br />PROPERTY Owner C_Leue.0,1 Address O. City SAY\ T4411401 Zipc146g3 Phone s- etopy x&C;iclen <br />LQ <br />COR-, Address r301.1 City ectrbil'iC#5q08 Fhone#91(0-&91-000 Consultant / Sub Contractor <br />C-57 Contractor Address 1 PI-load/2.5 -31.3 580,0 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 1] YES 0 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: [] S EL VC [] OTHER: <br />DEPTH OF GROUT SEAL 5E 6 -14,1.4 NA' TREMIE TYPE TO BE USED: (1 AUGERS )(HOSE <br />GROUT SEAL PUMPED: )(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: te--14 <br />r3W APPROX. BORING DEPT. 84',J 96' '(BOLTED TRAFFIC BOX or STOVE PIPE <br />TYPE OF WELL INSTALLATION TYPE <br />,MONITORING X-IOLLOW STEM <br />fl EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR n MUD ROTARY <br />1] AIR SPARGE fi PUSH POINT <br />U SOIL BORING fi HAND AUGER <br />[J OTHER: [1 OTHER <br />CONDUCTOR CASING PROPOSED? nivwr ( if YES, list specifications here): <br />'COMMENTS: Ce3C\ c•v ) 143e_ ctc ci.1O.QfV4s,,. <br />