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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 />SITE <br />MITIGATION <br />UNIT IV <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, C apter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 45R 72(i;-.- ' Ave, Cross Street Or ity 1-40/C-464::14 Zii%2d9 Parcel# <br />PROPERTY Owner Address 4632--r0ac i<lve_Q d ZipCij6 24V, Phone# <br /> <br />— / of <br />* 4 , i <br />Address &3.3 .---41-2::X/IZOCity A, , i - ZiRgY2—Lichone# 90 ble- 7Z7 <br />C.57 ContractorWS <br />Consultant! Sub Contractor A A-5- ' 1 /4- ( Address Bgi -5-1144.4) / y e/ Phone# Lin Ob 6, ,---A_L <br />_3478f# <br />GIS Coordinates: X <br /> <br />, Township <br /> <br />Range Section <br /> <br />.i <br />Air TO BE PERFORMED: <br />NE/ WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />fl WELL # <br />*Other: <br />COMMENTS: <br />fl DESTRUCTION (choose type below) <br />g OVER-BORE <br />O PRESSURE GROUT <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE SF tri al MULTIPLE CASINGS? a YES,W1O WELL CASING DIA:,%'? <br />CASING THICKNESS TYPE OF CASING: a STEEL etr -VC fl OTHER: <br />DppTH OF GROUT SEAL ?reel— TREMIE TYPE TO BE USED: Aii:8_UGERS fl HOSE ‘3\3 <br />GROUT SEAL PUMPED: g Yes No(ticla MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 45 OLTED TRAFFIC BOX or a STOVE PIPE <br />WiCTOR CASING PIOPOSED? ( if YES, list specifications here): <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, Rules and Regulations, and all applicable California State Law . - <br />Signed x 4,.tAt.% Title/Company )46C 6 Edeije,571 <br />Print Name WV f(C)— (-7-1-(-(.2_, Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: "gg ?ci <br />WORK PLAN DATED: OC--FEC <br />TYPE OF WELL INSTALLATION TYPE <br />O MONITORING 0 HOLLOW STEM <br />fl EXTRACTION [] AIR HAMMER/DRIVEN <br />[] VAPOR flMUDROTARY <br />[] AIR SPARGE [] PUSH POINT <br />O SOIL BORING a HAND AUGER <br />[] OTHER: [] OTHER <br />*COMMENTS: qrseliktli <br />ZOO Area I Application Accepted By adiJawil / lAY mate Issued <br />Grout Inspection By AfflaffMerj Date .4•TAIWo Final Inspection By Date <br />Destruction Inspection By Date <br />11.9 t!,) c,A) 71E1- —... — ----........._. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK #C" BY DATE # INVOICE <br />. ( r76 / jtif) OA ( )02,6 <br />C-57 WC -WAIVER C-57 Letter of Auth io t sign permit lncroacnment doc <br />