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5(c31 <br />WC -WAIVER C-57 <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 <br />WELL Location Cross Street City /47e: Zip 75 33 Parcel# Pit.? 4,(.... <br />Address <br />C-57 Contractor <br />Section <br />.8:NEW WELL / BORING() GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />WORK TO BE PERFORMED-, <br />43.-SOIL BORING # -'2 <br />WELL # <br /> <br />0 DESTRUCTION (choose type below) <br />I] OVER-BORE <br />PRESSURE GROUT <br />Grout Specifications: <br />COMMENTS: <br />,-H-:SOIL BORING <br />TYPE OF WELL <br />[]VAPOR <br />0 AIR SPARGE <br />MONITORING <br />EXTRACTION <br />OTHER: <br /> <br />INSTALLATION TYPE <br />fi=PUSH POINT <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 OTHER <br />O HAND AUGER <br />MUD ROTARY <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2-" MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA: <br />CASING THICKNESS /t-"/e) TYPE OF CASING: 0 STEEL 0 PVC U OTHER: <br />DEPTH OF GROUT SEAL "L/ ReA TREMIE TYPE TO BE USED: i(AUGERS B HOSE <br />GROUT SEAL PUMPED: H.Y-EIS 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /1-)< <br />APPROX. BORING DEPTH /5'0 I] BOLTED TRAFFIC BOX or 0 STOVE PIPE -4 <br />CONDUCTOR CASING PROPOSED? "th. (if YES, list specifications here): <br />.,i" <br />"COMMENTS: <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 ' c les a egulations, and all applicable California State Laws., <br />Title/Company C, da°7--C 7,79A04060 Gfear.i' <br />Application Accepted By V'..tD C>f--C4:-4YC)k-- Date Issued .34_7 / <br />Final Inspection By <br />COMMENTS / CONDITIONS. <br />SITE <br />MITIGATION <br />UNIT IV <br />'2-1V f ebleri — Csicz <br />PROPERTY Owner 170-4 0,i ,ecet — <br />Pr://,..-5 Address 95ei Cityffc.-4;-,-2 Zip 7y553 Lic# <br />gif,Address Li 8/ 0 ,10416-)0 City D.2, (;;//,/- Li ctt <br />Range <br />Consultant/ Sub Contractor <br />GIS Coordinates: X ,Y , Township <br />*Other: <br />City Zip Phone# <br />Phone# 9 - 3/3 -5-yee <br />Phone# 72.5 -F2-c. 5_3 9/ <br /> <br />Signed x <br />Print Name 7E324 V //#2# <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: a0 -7 QVi/vvl <br />WORK PLAN DATED: <br />Date / ZIO/ <br />Grout Inspection By C,C)-4- Lc) C----C-k-er) <br />Destruction Inspection By <br />Date <br />Date <br />Area <br />Date <br />35() <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AID# <br />AMOUNT REMITTED <br />C-57 Letter of Authorization to sign permit Encr-:;-c-Thic rarrrt-doc--- 9/27/00 <br />CHECK # <br />FAC# <br />REC'D BY DATE