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ORIGINAL WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />WELL Locatior z_sr 111.0 €371 Cross Street Ui ILSC))\-1 :ity '--(-ce.k,-14,/ Zip 7s-Kz. Parcel# <br />PROPERTY Owner aptraly lekt•rtlartdAddress I(010 . 141kZetfr.N. City S.1,,,) Zip <br />C.,-;th--" Zip C'S" 7 Yz C-57 Contractor C-c-sc,...eAt, Address C'sz, 0,--4-c Lt. City <br />S7 - <br />LiC# 7( 7S-IP <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 <br />Joaquin County Devph,nrn.,,t MIA r.hantr P-1115.3 and the Standards of San Joaquin County Environmental Health Department. es-r Assessor's <br />N/A <br />Phone#(?..)4`)Lg- 3o- <br />Phone#P(') //b5 <br />A% <br />Consultant / Sub Cntr 1.-/ Address / City nss--cc,- Lic# Phone# <br />GIS Coordinates: X tZ(` i (, , Y e:95 - , Township 2-/J Range C9F- Section <br />WORK TO BE PERFORMED: <br />WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U DESTRUCTION (choose type below) <br />fl SOIL BORING # <br />0 OVER-BORE <br />SLWELL # f) -'- fl PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />CO, <br />CONSTRUCTION SPECIFICATIO <br />") <br />DIA. OF BOREHOLE 10 MULTIPLE CASINGS? gyES NO WELL CASING DIA: Z -1" 0 <br />CASING THICKNESS 0. /Cr ut- (...AbiNU: fl STEEL VPVC B OTHER: <br />DEPTH OF GROUT SEAL .'52- TREMIE TYPE TO BE USED: 1CAUGERS 0 HOSE <br />GROUT SEAL PUMPED: fl Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />fl OTHER: 0 OTHER APPROX. BORING DEPTH "i5C - *KBOLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: -Be, 'L. ce,-( t-sf--c-ie Z V-, ix. pv.--r <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 pplication and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules andreg , ons, and all applicable California State Laws. <br />Signedx ,,,=.-----cf Title/Company S4.-if <br />Print Name C., , ,IfIC.,., Date cs-(WPZ- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (940 / i\S II/L,(49 ill 4'6P <br />WORK PLAN DATED: NO V -0/r fikile /--*/ f • 0 2- --- <br />Application Accepted By Date Issued 3 - —0_3 Area 0(20 <br />Final Inspection By C .4_111_-)_ .c. Grout Inspection By Date <br />Destruction Inspection By Date <br />-...cry; , <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE "MIT / SERVICE - • I 'm • INVOICE <br />36-1) I -)\LAA) 04:i 5-vl-ct aA. _3.3-0 - swe <br />TYPE OF WELL <br />`If:MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />I] SOIL BORING <br />INSTALLATION TYPE <br />'HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />fl HAND AUGER <br />C.% <br />-0 <br />C-57 V -WAIVER 1/25/02 C-57 Letter of Authorization to sign permit le-