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C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />GS <br />3oloo) <br />-doe 1/25/02 <br />WELL PERMIT APPLICATION FOS <br />*,i :\ <br />\C C <br />\ <br />, e • 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 Joaquin County , , . r \ / peVelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location CO--- it.)_ Cal,SYr A ‘ig- Si- Cross StreetCAe 5+- City 1 r) zip 95.1-0C Parcel#1 7 - tge-!34 - <br />PROPERTY Owner a r ql A ddress (.,-)()) A/ Cil 9+- City Zip 90-°5- Phone# 9'4/ - ().6.-- <br />C-57 Contractor / •ddress 3 C.:Za- OfieCei. CX . City (2L& 0 Zipl C7 Y) Lidt/ / 7vo Phone <br />I <br />? 4 <br />Consultant / Sub Contractor E Address C625-7 5/flak.) City‘14 7).Lic#6001.2>Phone# V67 - /6'06 <br />GIS Coordinates: X , Township <br />WI/ir <br />k TO BE PERFORMED: <br />NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />OIL BORING # <br />ELL # 4 va2 H 5 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ONITORING *OLLOW STEM DIA. OF BOREHOLE 8 " MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: az <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS4 CIA Lio TYPE OF CASING: 0 STEEL .)<DVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I-71 TREMIE TYPE TO BE USED: \kKUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes o (NOWE: MAXIMy1111 FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 61+64 (P _ 11e,11- <br />ijA t <br />0 OTHER: Ii OTHER APPROX. BORING DEPTH c-ifC/ OLTED TRAFFIC BOX or G STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ivO ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />Range <br /> <br />Section <br /> <br />*Other: <br />DESTRUCTION (choose type below) <br />J OVER-BORE <br />['PRESSURE GROUT <br />Grout Specifications: <br />(Th <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 County Ordinances, <br />Rules and RegI4Itions, and alJ applicable California State Laws. <br /> <br />44- (fr A6E Signed x Title/Company S+ <br />Print Name .127)('Ian M i 1 tiIi Date / C)2. <br />DEPARTMENT USE ONLY <br />S <br />;0 oct ccü <br />Application Accepted By 1-4.,•AneC4--.-- Date Issued 6 ( 1 2_ / C5 -2_ Area <br />Grout Inspection By (A..m/ti kt-,t4.A Date ,617-‘4(C37 Final Inspection By uNtivfripizt Date <br />Destruction Inspection By Date <br /> <br />COMMENTS / CONDITIONS: <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />frnL• <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 3---c ( S'-°( , CC-) ( 64' (--( 9 6(6,7/2/e) 2- SR# .: C ) I C )C-I