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��`° " e�, • SAN JOAQI.IIN COUNTY <br /> FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> Npwaone:600 East Main Street, Stookton, CA 95202-3029MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web:www.siaov.org/ehdUNIT IV <br /> APR 2 9 M09 WELL PERMIT APPLICATION <br /> ENVIRONMENT <br /> \/HEA <br /> QLTPION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is h�eEby TJA�b'S'aN�b'a <br /> pp y quin 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 sof San Joaquin County Environmental Health Department. <br /> Well Location 990��ecGlnuf Cross Street �p'�°/JT n1113 (//e• City I/p( Zip % Parcel#r 2 070 00 <br /> Property /��� <br /> Owner (_�L'/y ICU�I `�C, Address I/I �+ olti City /,� 0� Zip 723 Phone# /iJ�5�3^4� — <br /> C-57 Contractor ✓( Address J City (� Q Lic# Oil*-W Phone 530— &b—2-f2_9- <br /> Consultant/Sub Cntr C 2Q Address ?�(0( (j(�j 6W,R. �2�I city &aG /1�-So <br /> Lic#WPhone00 U/1U3�1 03 <br /> GIS Coordinates:X _(24 •4-5bbwo,Y Township 2-_90AA__ e Rang �T-Section 2 9 <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT GEOPROBE,HYDR UNCH,HAND-A GER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# tal�o)�i� ,t (q' b� ❑ OVER-BORE DIAMETER <br /> ❑WELL# T7 ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> l <br /> COMMENTS: O <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE f <br /> � El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑ PVC ❑ OTHER <br /> ❑VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL _ TREMIE TYPE TO BE USED❑AUGERS❑ HOSE <br /> ❑AIR SPARGE/OZONE ❑ PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS Tye �� Po✓ �d <br /> I <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> INDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: A igvkoX40 A So kA,j <br /> NOTE: OFFSITE BO INGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify th I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and I a plicable Califor a aws. <br /> Signed yy��kM, Title/Company <br /> IV J'( <br /> Print Name A4( a I LIVt'O,w Date Z o 9 <br /> �� � <br /> DEPARTMENT USE ONLY ��� '/�3� <br /> SITE MAP IN UNIT IV FILE,ADDRE lY�` <br /> WORK PLAN DATED: <br /> 04 F 0i ge <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DA E PERMIT/SERVICE# INVOICE <br /> Zgo l6 31,6 - S R# Z 3q <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TOR E _G"�OACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />