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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.siaov.orp/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. <br /> Assessor's <br /> Well Location q Street City Zi r.Parcel C)-2.O— <br /> Property C� <br /> Owner `\mow. wo'\"- s Address 05 �'���h�•�.\\n Clty2 N.�c\r- ip SGS" Phone <br /> C-57 Contractors .,a`�SL��f�\`AddreSs r LfvrP Q. u.ti\City `�l # \ ` Phone <br /> C sui antlSub Cntr�f's C 1�`, ^ d ess� al w�S� �. City -��- Lic Phone ao�' <br /> GIS Coordinates:X Y Township '��-a Ra 1= Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER' D ON(CHOOSE TYPE BELOW) <br /> t©'SOIL BORING# ORE DIAMETER <br /> ❑WELL# ❑ SSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONST CTION SPEC I TIONS <br /> ❑MONITORING ❑HOLLOW ST DIA.OF B EHOLE �� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/D CASING I NESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑M D ROTARY DEPTH OF GR T SEAL S TREMIE TYPE TO BE USED❑AUGERS El <br /> c,�; ,� <br /> SPARGE/OZONE U H POINT(GP CP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑ DAUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑O R: APPROX.BORING DEPTH S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (Ir YES,list specifications In comment section) <br /> COMMENTS: <br /> NOTE: OF TE BINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> Aslication <br /> ORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I Have lrepare arld that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatlons, d II app ble Cas. A 1 <br /> Signed Title/CompanyS3�2xF T"" tr/ G2r..sz \S <br /> n r-� <br /> Print Name %%j O N Date 6 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 9 3,Z FY O-,L faa e— <br /> ` r1v' <br /> WORK PLAN DATED: N 0 N 10'e, S <br /> APPLICATION ACCEPTED BY V;e—t0 f i a Me(�'&ri77 e>„ DATE ISSUED L DAREAJ4Sg <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Ad yanc ern B1LJL Of OYt e_ S f1 n ) LTJ Dr I�,2G <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 201 D 89, ov 24'77 �'�/ 4�L JD SR#6oS9GT9 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />