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t .-. <br /> SAN JOAQUIN COUNTY � <br /> N `?AENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> F. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> :P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> / opN <br /> WELL PERMIT APPLICATION SBI 0X <br /> ti <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D <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 9Lss <br /> 15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> '// SAA <br /> CAM <br /> Assessor's <br /> Well Location y0(�• ��e4C� � Street S A "1 S/fi City !`P A CAM Zip y 5a 3, Parcel#/q3-Pro <br /> Owner t C9 ( Address 3`{or cJMw CitA,.., Zi �Phone# 5"63�/ <br /> C-57 Contractor (-,1-egq_ �J�`1(I'Ry Address qn 14ot)e fzs City i n e Lic# S I�Phone 75) t � <br /> - O'L <br /> Consultant/SubCntr,, �+e.0 Address-3017 h0)e- City JCE? Lic# Phone lrrA(-OW <br /> GIS Coordinates:X ;u:r ,Y 216T Township ( 1 S Range G Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT, <br /> IC$] GESROBE,HYDRpUNCH,-HA�ND-�AUrGE+R,OTHER•) DESTRUCTION(CHOOSE <br /> TYPE BELOW) <br /> � f El DIAMETERSOIL BORING#-5 8 6 0 t sa � J4 9&/ <br /> WELL <br /> PRESSURE GROUT <br /> ❑`OTHER S'00 GROUT SPECIFICATIONS <br /> COMMENTS: 'f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER • <br /> ❑VAPOR 0 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 /> X011- ` <br /> BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> i CONDPCTO3 CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �Q �o E�OOP4?bL Sal ,b0J`,U1f3 40 G W)c ')L, <br /> U' �S <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable <br /> ( Califo nia Laws. <br /> Signed Title/Company l e-C SI J <br /> 4 f 6,A1,2, <br /> Print Name Date <br /> !� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (D I �C <br /> WORK PLAN DATED: 1-6 <br /> IF <br /> APPLICATION ACCEPTED BY Y4 iii DATE ISSUED AREA 06 <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 DAT PERMIT/SERVICE# INVOICE <br /> y4D <672os� 6 oq s # y <br /> C-57 V, WC -WAIVER C57 LETTER OF AUTHORIZATION TO§-IGtIPERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />