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FORM <br /> WELL PERMIT APPLICATIONSITEMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 dtQ <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Johau�teC9-11 5 3 and the S anda ds of San/Joaquor in)County Public Health Serviceule work described. Irlis s En�ronmen 15 ntal Health e in )Division. San <br /> Joaquin County Development Title,C p Assessor's <br /> '`` l� t � ZipZ-Parcel# <br /> WELL Location � YDS� � I��Cr Cross Streets�� C��ty/ ;'�� <br /> W 4�-�? Bw City _ Zip!Q Phone# <br /> PROPERTY Owner ADL' P•I'�_ Address r- �_ ,y1 j/7��y� '( SI�0 <br /> -T- AddressCiry3��"`�"T��'T�'�Lic# hone# <br /> C-57 Contractors 11 [, �� 93 <br /> Consultant/Sub Contractor <br /> fb��lLl.�P�1=�ad-s f'77q� �1�D��1City,_ C.oD( Lic#Phone#3 - <br /> , <br /> Range Section <br /> GIS Coordinates:X Y Township <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') []OVER-BORE <br /> SOILBORING# ' PRESSURE GROUT <br /> DWELL# �'�IIC- L-�i)w� <br /> Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE_ OF WELL INST LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> OF CASING: 0 STEEL g� I]OTHER: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS u TYPE TREMIE TYPE TO BE USED: t<GERS 1�HOSE <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL SO <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE .MGIIMM M FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER � <br /> 0 <br /> GROUT SPECIFICATIONS: � �� TED TRAFFIC BOX or STOVE PIPE <br /> 0 OTHER: ^ <br /> 0 OTHER APPROX.BORING DEPTH © r �v` <br /> CONDUCTOR CASING PROPOSED? (Z(if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ADVANCEFOR <br /> ENCALL ROACHMENT <br /> PERMITS.. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURSI <br /> I hereby certify that I have prepared t ' application and that the work will be done in accordance with San Joaquin <br /> County O nces u s d Reg a ons, and all applicable California State Laws. <br /> i� Title/Company G <br /> Signed x 0 2_ <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 30O 5.-0-2— <br /> WORK <br /> ._O2WORK PLAN DATED: b6 d5( <br /> Date Issued Area�— <br /> Application Accepted By Date Final Inspection By Date_- � <br /> Grout Inspection By <br /> Destruction Inspection B., Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3g <br /> 9/27/0( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />