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SAID JOAC UIN COUNTY <br /> Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.si-ov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE 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. ,a'S <br /> Assessor's <br /> Well Location tray Cross Street/t. (rdden !a�e Av*• City 5f vc�tA fK-A Zip Parcel <br /> Property <br /> Owner U;.SgQ ra R�/��QS LLC- Address kb S ox I b City ti+ewtwj- Beach Zip q Z"-L Phone# <br /> 4,838f�s <br /> C-57Contractor T�%$c-Vt QAAr'*Awe.n�gtAddress 3I SD �oh�S� Rd� City tty�eSv;1�� Lic# Phone(7e"1) -7b,g- 191W <br /> Consultant/Sub Cntr Address!!, City tS L a I t--, Lic# Phone T; <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 9 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> I SOIL BORING# 461 ; 4 8q, 5 B 5-i ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Zit ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 45 TREMIE TYPE TO BE USED <br /> ,J�AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes`p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [:]HAND AUGER GROUT SPECIFICATIONS Next Gtr"-°�+k I�Ird u <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH '-; / ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMiENT 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,ann_11 applicable Califo <br /> Signed �� `� �/ Y Title/Company �"tPO�ld ►�tc.. /�s� <br /> Print Name L� l Date `t ►�J��9 <br /> DEPARTMENT USE ONLY <br /> I <br /> it <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �^t �'J''!V i l..%� "d <br /> WORK PLAN DATED: 4 H-7 <br /> APPLICATION ACCEPTED BY ff DATE ISSUED Ll /� AREA <br /> h� <br /> 1 f� FINAL INSPECTION BY �l� l-(:: L� ? DATE <br /> GROUT INSPECTION BY L <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 PERMIT/SERVICE# INVOICE <br /> zap %ct,,�7,7 <br /> C-57 WC J -WAIVER C57 LETTER OF AUTHORI ATION TO SIGN PERMIT ENCROACHMENT DOC <br /> T WELL PERMIT APP <br /> EHD 29-01 11/5107(WEB) <br />