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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <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 Environmental Health Department. <br />WELL Location 2,50( Cross Streetn City&LC3CaCt1 <br />Assessors <br />Zip Parcel# <br />c../0 L. PROPEttTY ic‘ <br />Owneri-h <br />3 <br />'Cr...ell—crize-tb,&-e-ts Address 2c177 "re{neAr.:z ‘/cst‘c ifft4-5`78 Phone# <br />C-57 Contractor C.DC-Cf.:A.Cc--.t U.t <br />Consultant! Sub Cntr CD7 <br />LiTtn <br />GIS Coordinates: X tC5 6,G0 /53q E. <br />WORK TO BE PERFORMED: <br />?d,NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />['SOIL BORING # <br />"..41WELL # <br />"'Other <br />COMMENTS: M.Jo C-N2LL Is<'-lo;Th‘ <br />9-) <br />INSTALLATION TYPE <br />OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS4Fs'Jn TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7•5A.-- 6,-r> TREMIE TYPE TO BE USED. 0 AUGERS <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTVIAXINUM FEE-FALL DEP <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO S C...)-1-11-t fq.C>iThl,.. <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH CV!) 0.4 `On OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 1-1.13 (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordin ces, Rules and Regul tions, and all applicable California State Law <br />' V <br />Signed x Title/Company <br />Print Name ...\---\,--11:5 e----\ C\ A l. .1, Aq Date k 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />RECEMED <br />FEB 19 2004 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />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 />SITE <br />MITIGATION <br />UNIT IV <br /> <br />AddressCISOOI S, CityGLi 4 Lic#051k5 Phone#412.5-30 -SSCA•O <br />Address 2.efr A\ City-4-.0-40-01 <br />, Y , Township Range •Z‘E.-• Section <br /> Phone#ql - 2.O <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE. DIAMETER <br />1:1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />7 <br />E(-11/10 N I TOR I NG <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />OSE <br />IS 30') <br />(OPAce' / Date Issued Area <br />Final Inspection By litA p r <br />/ <br />ate .4 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE ! ."j. C E REQUE 1-itt, <br />3501 2 51 . 00 2 ci 3 9 't\i-- I z/i /o SR3 5 <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Auth sign permit Qachment doc 9/30/02 <br />