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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date Issued e 1171" F _ea <br />Final Inspection By Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' ,BY DATE PERMIT / SERVICE REQU T # INVOICE <br />to <br />-WAIVER C-57 Letter of Autho <br />q <br />sign permit doc 9/27/00 <br />c-2„lo <br />C-57 WC <br />\\\ <br />WELL PERMIT APPLICATION FORM <br />v.‘kr <br />0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />0(1--c6 <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />\ <br />SITE <br />MITIGATION <br />UNIT IV <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 (0Z5 IV- Sari 1-194_rivt Sk Cross Street Fork Sfr ed City Sh,C4-1-erkt Zip Parcel# /3?-0(oo -11-/ IiL3 <br />PROPERTY Owner ROOD C4ilepA Address / 5-36 iv. M)NTER. SE City4C1 14 Zip__Phone# <br />C-57 Contractor 6-11 arsiny Address 9r2 1-/OGVE RA City iliftiAN27-- Zip 61- Lic# Phone# 5V5-313-6300 <br />Consultant / Sub ContractorCOK‘r ;414 le • • • :5Address 1:.; Ask Wegi• 6r, le... rCity 5761Dif Lic# Phone#299231-05hg ' <br />A <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') B DESTRUCTION (choose type below) <br />)-SOIL <br />- <br />ArSOIL BORING # if 0 OVER-BORE 0 <br />0 WELL # XPRESSURE GROUT <br />*Other: Grout Specifications: c :541\ <br />COMMENTS: 6_errz,he -4 .. 30 ': 6r4b i,,,,ger/ 412,a,,f 4-0 ha) at.- ti44.41/6'lry <br />GIS Coordinates: X , Y Township Range Section <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING 0 HOLLOW STEM <br /> <br />0 EXTRACTION []AIR HAMMER/DRIVEN <br />VAPOR D MUD ROTARY <br /> <br />a AIR SPARGE 0 PUSH POINT <br /> <br />fl SOIL BORING 0 HAND AUGER <br />OTHER: [J OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES fl NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC [J OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />GROUT SEAL PUMPED: fl Yes UNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 Ordiqn9es, ules and Regulations, and all applicable California State Laws. <br />Title/Company De; <br />DEPARTMENT USE ONLY <br />Signed x <br />Print Name Date