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SITE <br />MITIGATION <br />UNIT IV <br />-PSED <br />Fc t3 - 20(36 <br />ENMBONMENT 1-1EPITH, <br />WELLSERMIT APPLICATION FJRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />Zip ?5,24fhone# /777 <br />City-ith_r_Zip?c(iLic# Phone# <br /> <br />City 1-76/4.1/<'W Lic# 1-/aW--3 Phone# f>_.? <br />PROPERTY OwnerkSe Cal Address V.Z,5-r-7 ,xx City <br />C-57 Contractor / 4/ AddressN //e/' <br />Consultant / Sub Contractor /47 cro Address,2997 <br />GIS Coordinates: X , Y , Township <br />0 DESTRUCTION (choose type below) C- <br />O OVER-BORE (St <br />PRESSURE GROUT <br />WORK TO BE PERFORMED: <br />pa<NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />0 SOIL BORING # <br />p0 WELL # 3 )4 4//i <br />*Other: Grout Specifications: G-751.s" <br />COMMENTS: <br />*COMMENTS: 14-ro v. a i,5%ex 6 <br />PE CODES FEE INFO <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 />Assessor's <br />Cross Street 7////e Ze'te//S City 5-7"-- Zip 75-)Gdriparcel# 4-3-3/(9-,e97 WELL Location 5-7 j/),,, <br />CONSTRUCTION SPECIFICATIONS Z... ./.. <br />DIA. OF BOREHOLE g" MULTIPLE CASINGS? 0 YES jIyho WELL CASING DIAe-2 e <br />CASING THICKNESS `7" TYPE OF CASING: 0 STEEL itiPVC 0 OTHER: <br />...-.)s' <br />DEPTH OF GROUT SEAL CL-- 5- ' TREMIE TYPE TO BE USED: XYAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes At (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'17-d_ <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH (.9 C'i / At OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CO UCTOR CASING PROPOSED? /1 ( if YES, list specifications here). <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />a*ONITORING Vi 0 L LOW STEM <br />B EXTRACTION AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />AIR SPARGE fl PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: U OTHER <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, Rules and Regula ions, and all applicable California State Laws. <br /> Title/Company /tr=25- <br />Afr-w <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: I ( 610(. <br />Application Accepted By <br />Grout Inspection By Date o Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS/CONDITIONS AAA,/ CI) P <br />ACCOUNTING ONLY: <br />INVOICE <br />3C0l j 110 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />3rb,3 27Y V7.51 Pt_ 1/C/06 <br />1 <br /> REC'D BY DATE <br />SR# <br />AID# <br />AMOUNT REMITTED CHECK # <br />DEPARTMENT USE ONLY <br />20S 1^ <br />) <br />Date 7? <br />Date Issued Area q 9 7 <br />Range Section <br />Signed x <br />Print Name e