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VIDESTRUCTION (choose type below) <br />9 OVER-BORE <br />VPRESSURE GROUT - <br />hr.,/ <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 ard/or install the work descnbed. This applicltion is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards ci San Joaquin County Public Health Services, Environri/e, dal Health Division. <br />Lo '93.2,07 Parcel#Assesr5,7" V10 41 <br />cAri,416', e# <br />PROPERTY Orme( j Address City P hon 201 9`f1-2-7// <br />C-57 Contractor Uieoalchidf Address /9-6' 19cix 736 ctYRob iViri- LP 91,57 / Lic#7/Cx'n Phone# 7 3 <br />Consultant / u/olehiGeb -,y, Address )3i 6 (15:Nne). 5-1L city/ Lio# '130 Phona# 5a1,C.C74:95340a <br />GIS Coordinates: X , Y <br /> <br />Township ,2 A-/ Range g section 2/ <br /> <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />"'WELL #_ <br />Other. <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: •-,. <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: -\.1 <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE' ('\ <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER: 0 OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (it YES, list sper_ificati(xis here) <br /> T\ <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 Ordina nd Regulations, and all applicable California State Laws. <br />Titte/Ccmpany g <br />cc/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 6.2":5 <br />WORK PLAN DATED: <br /> <br />Date Issued 4440 <br />Final Inspection By "sate 9-1 P -**6 <br /> <br />Applicalion Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Date <br />Date <br /> <br />COMMENTS / CONDITIONS: 1- Z7ty r wi ___ , <br />FArt ACCOUNTING ONLY: AlD# <br />PE CODES FEE INFO AMOUNT REMITTED <br />_ <br />CHECK I REC'D BY DATE PER„).111./cFavic:F REoU INVOICE <br />---,f .:2— o/27/no <br />..W A TVP r I of ton rif A tisrI7th1'It <br /> <br />RE r-Q y.L17. <br />SEP 2 0 2Q01 <br />ENVIRONMENT HEkLin <br />PERMIT/SERVICES <br />SITE <br />MITIGATION <br />UNIT IV <br />4NNAJD <br />WELL Location (e9 VI- 7 5 I; Cross Street Aar // city ______ <br />ke,Me Fohilicirp}1, 7700 7* 0086 <br />Grout Specifications <br />'COMMENTS: <br />Signed x <br />Print Name <br />Date