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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY UNIT IVTION <br /> ��. ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 51 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> \\\' (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ap lication 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 Joaquin County <br /> S�eVelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> / II t ��� Parcel# - l s sso_r� <br /> WELL Location 60- J, LClt r n l� 5� Cross Sttreet(9 ) S//� City Yl Zip u <br /> PROPERTY Owner &a r1_ ddressgb[�� V. CA (� CZ-5 Zip l?_ Phone#' Tq <br /> C-57 Contractor /n ddress 3 LNt�L U. City t`�n L ZiPIsl`� Lic#Phone �� <br /> Consultant/Sub Contractor kT-E Address ;- Y City Lic#�Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# c� (p�� 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t / 00 <br /> / 11 <br /> 'MONITORING OLLOW STEM DIA.OF BOREHOLE 00" MULTIPLE CASINGS?0 YES;KNO WELL CASING DIA:1 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5& YO TYPE OF CASING: 0 STEEL �KFVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL l7t TREMIE TYPE TO BE USED: VUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0. (NO1E: MAXI FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING G HAND AUGER GROUT SPECIFICATIONSAA: �Y G qie l <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH t1V OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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 County Ordinances, <br /> Rules and Reg tions,and alb applicable California State Laws. J '— <br /> Signed x Q /`(fit/^r( Title/Company <br /> Print Name C J�ILtV1 /t/`1 �M-TI,, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6o Z C S' S jr�c foL <br /> WORK PLAN DATED: �70 <br /> Application Accepted By / n� Date Issued 6 Z b-2 MArea — <br /> d <br /> Grout Inspection By L MArtAA Date Z Final Inspection By DateZ <br /> Destruction Inspection By Date / C <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />