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SAN JOAQUIN COUNTY <br /> z ONMENTAL HEALTH DEPART°t„�tNT SITE <br /> a ` 171= st Main Street, Stockton, CA 95202-3029 MITIGATION <br /> RgQ We:(209) 468-3449 Fax:(209)468-3433 Web:wvwv.smgov.org/ehd UNIT IV <br /> Q`�FOR� NOV o 5 zoas <br /> WELL PERMIT APPLICATION <br /> ENVIR04N1 NT HEATH <br /> ��R��Tj. NDABLE 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. Assessor's t <br /> Well Location t� Cross Street �rka \� City "tco. _zip 9'�3� Parce!# e�n10\ tea*we <br /> Property t Zi 'S Phone# - b <br /> Owner" y d+ =c c/ Address �+�� One, Cada a7�- City p 1� <br /> ou�e. jZ1, Cit N11r.r�+ nc..2 Lic#c� hone�q26)313-5$00 <br /> C-57 Contractor Address y-.�--�—- <br /> Consultant/Sub Cntr Address01 t2,. �city „Lic#b5` 8 Phone11(r 5 -0 - <br /> GiS Coordinates:X Y Township <br /> 'Se�,�1ti Range_ -A—Section <br /> WORK TO BE PERFORMED: tA DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑OVER-BORE DIAMETER <br /> ❑SOIL BORING# 5 PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS <br /> ❑`OTHER <br /> COMMENTS: <br /> Gr�SI <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 HAMMER1DRIVEN 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 SPARGEIOZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH 1S 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (rf YES,list specifications in comment section) <br /> COMMENTS: <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 California Laws. <br /> Signed Title/Company 6-CA-qi <br /> Print Name yekpipA Date 11 I Looq <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2-S&0 !2v�a.+,t ^(tAk ffl==-1P <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED L+11--V-02 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 DATE PERMITISERVICE# INVOICE <br /> 315-02 40.co 2-2l-'eZ 0 11 jZ4jog SR#.Ssst tO <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(VJEB) WELL PERMITAPP <br />