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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main street,Stockton,CA 95202-8029 MITIGATION <br /> Telephone:(209)488.3449 Fax:(209)468,433 Mb:Y-Awslaov.ora/ehd <br /> UNIT IV <br /> i <br /> WELL PERMIT APPLICATION <br /> NONREFUNDABLE PERMIT EXPIRES 1 YFAR FROM DATE ISSUED <br /> Application is hereby made to San JongUln County for a pend to mnsMvu and/or Imiall the work dwm-md.THS apPitrallon la made In oompllanoa with San <br /> Joaquin County CevefppmentTw%Chapter 9.1115.3 and lhd Stejgldards of San Joaquin County Envlmnmardal Healdl Dapaernent. <br /> H`sptxatlan 1111 , Class5haRt / /� _Clly&JG im Zlp Z� PAarcelt! 157oy <br /> Prone 4t'r } �lA I65 , LLUYt Addrasa _ Po l3ox S��ZS l�� � <br /> Owner hr C9 city Zip �I Phonerri��/C�C1 ,{fRr�2''77 t}s, <br /> G57 Contractor YIl ` Address I Ctry r�',I,,rp}�.lC}•,,, ;ip Lict Y 4716 Phone`?SA�/ If <br /> OOnaammUSUbCn Addreas_�j Gly LI,9 Phone <br /> GIS Coorcinatea:X ,Y ,Township Range Sedan j <br /> WORK TO BE PERFORMED; <br /> 3Q NEW WELLIEORING(OPT,GaOPROSE.HYDROPUNCH,HAND-AU040,OTHER') DESTRUCTION(CHOOSE TYPE BOLOv4 <br /> SOIL BORINGp I OVER-BORE DIAMETER i <br /> Q WELL ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATioNS <br /> COMMENTS: i <br /> TYPEOFWE L MUAI , TtON_TYPE _ C0142TRUCTION8156. ICATIONB <br /> ❑MONfTORING ❑HOLLOWSTEM DIA OF BOREHOLE: 0MUlTI71.E CASINGS❑MULTI-LEVEL WELL CASING DUu,._ { <br /> El EXTPACnoN ❑AIR HAMME^RORIVEN CASINO THICKNE39 TYPE OF CASING:❑STEEL Q PVC ❑ 07NER <br /> VAPOR ❑MUO ROTARY DEPTH OF GROUT$FAL-l _o—7REM15 TYPE TO Ba USED II AUGERS❑NOSE , <br /> ❑AIRSPARGFJOZONS �4 PUSH POINT(GP OR CPT ,GROUT aEALPUMPED:fly"❑NOQ(NOTTI M[yLIMUM FRET-FALL DEPTH 1930') t <br /> ❑SOIL BORING ❑HAND AUGER GROUi9PECIFICATI0N3 <br /> Q OTHER: B0771ER: APPROX.ACRING DEPTH _ V Q VIOLTEOTRAFFICSOX OR ❑STOVEPIPE <br /> CONDUCTOR CASNOPROPOSM Ia1P,A i1yTaFeOAeeemalnearv,eateeelm) <br /> GOh1MENTS <br /> NOTE: OFFSITE SCRINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> aR WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I Hamby mlIN that I have pmparod this applicatlen and that tho work will be done I accordanoe with San Joaquin Courly Ordinances,RIJIMEnd <br /> mations .{d1��1j�jP�p}hca alifami I LawS. ,Q <br /> Signed r ""�*'�' / TlelCompanySiQi� r2810 )'Sy• rI"T OG)/A <br /> A , t1 5�gra I <br /> PtintNama 1'Q ,Qf'" Iy, Son Dale <br /> DEPARTMENT USE ONLY <br /> BTFEMAPINUNTr IVPILE,ADDRESe: S mc,t+ S-I-VtC r -'r"TWT i <br /> WORK PLAN DATED, tit low IF .n P Y i <br /> APPLICATION ACCEPTED BY / _ DATEISSUED S 2-r 0 AREA <br /> GROUT INSPECTION BY _t A.r-%A A ..an.� S�z 1 /O-FINAL INSPECTION BY I�l.�;�.,� -- DATE <br /> DESTRLIOTION INSPECTION BY DATE <br /> COWANTSCONDITIONB: <br /> _ I <br /> - I <br /> ACCOUNTING ONLY; AID% FACE <br /> PE CODES PER INFO ANT REMITTED CHECK# RECV'D BY DATE PERMMERVICE9 INVOICE <br /> i <br /> 3 s o1g ce l SR# $ 305 <br /> C5 _vc _.WAIVER CMETTUFO—FAUT 40RIZATIONTO SIGN PERMIT ENCROACHMENTDOC <br /> j <br /> Emo? 11W %tLL FSRMR APP <br /> I <br />