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SAN JOAQUIN COUNTY <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.sipov,orglehd UNIT 1V <br /> WELL PERMIT APPLICATION "FILE COPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlorinstall 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 Hbalth Department. - - <br /> G Assessor's y <br /> Well Location .L� T��(3�i f7 �C4s Street �, _ City Zip`f Parcel# ��r;"/ <br /> Pro pert J G � Z(Gj phone#42p--4 <br /> Owner f Address ��'� �jj r�(w�.�,cryl city j Zip <br /> C-57 Contractor' Address ��� �!'1Lu� Lid Cit � VL ^� Zi`0�_Lic#,M02Z) P&ff <br /> ,�� yy 17 l L <br /> Consultant/Sub Cntr /4 Address LI City n Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .©'NEW WELLlBORING(CPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING El HOLLOW STEM DIA.OF BOREHOLE !W2\1-r bl di-TIPLEy CASINGS El'MULTI-LEVEL WELL CASING DIA:— <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS /OrTYPE OF CASING:❑STEEL ❑PVC ❑ OTHER p <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5_42i.i. TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> El AIR SPARGE/OZONE A PUSH POINT(GP OR CPTVP GROUT SEAL PUMPED:❑Yes 0—No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> J,��Ol BORING ❑HAND AUGER GROUT SPECIFICATIONS Gin^���r�fi�.iC—�! <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 45 qu_ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Gst specifications in comment sectbon) <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,andallapplicable Cal <br /> if <br /> ornia Laws. <br /> Signed LL LC L.fit_..�� ; i� TitlelCompany ez— °I'�j t — 0 <br /> }f li <br /> Print Name Dake d <br /> DEPARTMENT USE ONLY =' ' r l' <br /> pp IJ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: G? 2 E ti 5�` �T" n+ � G /'� <br /> VVORIC PLAN DATED: J 11 1 �/9 <br /> A.PPLiCATiON ACCEPTED BY td,A 4n 1 i+ �-�.� ++ DATE ISSUED -!3' r" AREA �' <br /> rf��_ ,:�c�/� <br /> GROUT INSPECTION BY 'iJ(a+ fr"2C�G' >�f _ ,FINAL INSPECTIONi- <br /> �l !',III 1!vLl 1l7:Li.i <br /> DESTRUCTION INSPECTION BY J Id— DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PF CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMITlSERVICE# INVOICE <br /> x5- <br /> 03 99 1�7 <br /> 404 . Oe) 2-Cl Z ! 13 1 Q SR#oo r6 3 0o <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-011115107 WELL.PERMIT AFP <br />