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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection <br />i <br />/ • ' <br />APILW/AriftWAIDate <br />Date <br />WELL PERMIT APPLICATION FOR, <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 />LIL1 07 E. (A;t764-100 . Cross Street City 51-er-k-6/1 Zip 95:31 Parcel#057100-SY Assessoep <br />WELL Location <br />PROPERTY Owner .ca‘tve5 -1-' )0, hn eccti i Address W02 E (4)'tier100 City .5+6Z-k-401 Zip ys-9) /5"Phone# 93 I ,)(i' 5-0 <br />C-57 Contractorrac, CAL e, (1, Address 31b5 ;-• Otile( C ird'e City Pa VIC14 p zipqM) Lic# 7S1 OPhone#6(100 )-Oci <br />A COrdOV <br />Consultant / Sub Contractor A 6-6 Address g 3-7 S fid , City Sitleibo Lic# tod).7 Phone# <br />GIS Coordinates: X , Y <br /> <br />, Township <br /> <br />Range Section <br /> <br />SITE <br />MITIGATION MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, 9EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />XSOIL BORING # 5 50 tom nct5 <br />i] WELL # <br />*Other: <br />COMMENTS: <br />U DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />a MONITORING I6OLLOW STEM <br />a EXTRACTION U AIR HAMMER/DRIVEN <br />fl VAPOR El MUD ROTARY <br />-fl AIR SPARGE a PUSH POINT <br />;(SOIL BORING Q HAND AUGER <br />fl OTHER: a OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE C?:>" MULTIPLE CASINGS? a YES 0 WELL CASING DIA:r(th <br />CASING THICKNESS NA TYPE OF CASING: a STEEL U PVC U OTHER: <br />DEPTH OF GROUT SEAL Err-lr-i TREMIE TYPE TO BE USED: U AUGERS 0 HOSE c‘ <br />GROUT SEAL PUMPED: g'es U No (NOTE: mAximym FREE-FALL DEPTH IS 30') 0 <br />GROUT SPECIFICATIONS: l‘o ?Dr-144d <br />APPROX. BORING DEPTH d-C ‘ -10 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED7VA ( 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 Ord ances, Rules nd Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />Print Print Name <br />/-` <br />g (Girl <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Toe) <br />ate Issued CLAW -4-* 2.200 I Area <br />nal Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC.# <br />AMOUNT REMITTED CHECK # <br />I 5 tp <br />PER ST # INVOICE <br />PE CODES FEE INFO <br />3501 <br /> <br />Y1.00 <br />C-57 WC -WAIVER <br />RE 'D BY DATE <br />U21 Zoo <br />R# <br />sign permit •achment doc <br />i <br />9/27/0C C-57 Letter of Auth ri t