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Date Stoned x <br />Print Name DEPARTMENT USE ONLY <br />srre MAP IN UNIT w FILE, ADDRESS: <br />WORK PLAN DATED: <br />ApioticatIon AccePted Sy <br />Grout Inspection By <br />Destruction Inspection By <br />C-57 C -WAIV Ct C-57 Letter of Author <br />Date Issued <br />Final Inspection 5y <br />sisn perInit <br />'Other: <br />COMMENTS: <br />AMONITORING <br />ri EXTRACTION <br />13 VAPOR <br />o AIR SPAR GE <br />a SOIL BORING <br />a OTHER: <br />CONSTRUCTION SPED iFICATION S <br />01A, OF BOREHOLE <br />MULTIPLE CASINGS?D YES U NO WELL CASING DIA, <br />CASING THICKNESS TYPE OF CASING: ['STEEL p PVC (1 OTHER: <br />OVTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: (1 AUGERS 1 HOSE <br />GROUT SEAL PUMPED: fl Yes C No <br />(NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br />C BOLTED TRAFFIC 80X or tISTOVE PIPE <br />(If YES, list specifications here) : <br />INSTALLATION TYPE <br />I] HOLLOW STEM <br />El AIR HAMMERIORIVEN <br />11 MUD ROTARY <br />11 PUSH POINT <br />(I HAND AUGER <br />OTHER <br />GROUT SPECIFICATIONS; <br />APPROX, BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <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 />NELL Location Sft2c,0-orl (MC re r City' 5 Zip______Parce10 IC7 <br />Assessor's <br />PROPERTY Owner4a44.5,6Mcl-C-006--Address <br /> E 1--City 5 an_ l.fleti_Phortetit <br />C-57 Conlractor cldress <br />Ity Zipa/-12_- LLic:02W±I_Prtone# 374 - 4340 <br />Consultant / Sub Contractor 6-Irff-[E__41g—•—eevi4C•Aeldress 0 City —Lic45D3121._Phone0.51 - _ <br />RanQe <br /> GIS Coordinates: Y Township <br />SectIon <br />I <br />NEW WELL / BORING CPT, GEORROSE. HYDROPUNCH, HAND-AUGER, OTHER') WOR TO BE PERFORMEot <br />B SOIL BORING It <br />El WELL # <br />'COMMENTS: <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 Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />Title/Company <br />SITE <br />MITIGATION <br />UNIT IV <br />Nom-REFUNDABLE PERMrr EXPIRES 1 YEAR FR M D TE ISSUED <br />10;,cirneetoritTSaitineJCOahoeuiptnerOznytr for:npdairtimeitstotancondasedtrus asnadniojraiancistuainll theuwnotyricpudeseccrivibglihThisrilespholtniovni is mmeentinHceaornitrligio.,Tovrilith San <br />loft icinct <br />fl <br />lunItlyerljty:ema <br />0 <br />0 <br />Grout Specifications: r•sza C <br />IKOESTRUCTION (choose type below) <br />) <br />OVER-ORS <br />(l PRESSURE GROUT <br />01 TY /ob,