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Sank JOAQWtNI COUNTY <br /> I`_ ',IVfRONMENTAL HEALTH DEPARTMENT SITE <br /> YID =' 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> at"- `Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.orq/ehd UNIT IV <br /> - , <br /> <0, 1:, 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. Q3 ,,.- <br /> Well Location L OWL) u�d ! Assessor's <br /> q V��Cross Street N. Ir aldw f>•-o,fe �t�. City SZ�c.�-fvin Zip Parcel# <br /> Property <br /> Owner C!-0-\ LL-L Address $0 13,0-K I I to City A)C dQ-''F I5ec-­IZip cl Z Z Phone# <br /> C-57 Contractor Address 31K° City S1-O Lf" '^ Lic#7701 a q Phone 71- Ub <br /> Consultant/Sub Cntr lr--­ & -JQ�ro Address 11/"I City F_< <a Lic# Phone b,t$-9'XS16- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> F1 WELL# M W S ❑PRESSURE GROUT <br /> ❑*OTHER _ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> F <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING `([j HOLLOW STEM DIA.OF BOREHOLE `6 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: i 1 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS sC-k• `" TYPE OF CASING:❑STEEL rp4PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL W 3 TREMIE TYPE TO BE USED J9 AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:E,RYes ❑No (NOTE:MAXIMUM IFREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS IJ f h4 C e,4-,.-(— <br /> OTHER: <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH I'D ABOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (if 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 La s. <br /> Signed V Title/Company Lr QJ �i i 5 /G'ro �✓� Z Q u <br /> r <br /> Print Name `� °e- q Date 741310 <br /> C � <br /> q DEPARTMENT USE ONLY �+ / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l U 4d - J�Clci_-), . <br /> WORK PLAN DATED: c, <br /> APPLICATION ACCEPTED B3Y DATE ISSUED 7 Q ( AREA-3 6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE `1—r <br /> DESTRUCTION INSPECTION Y DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC t <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> [/ ?L01 G SR# .3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />