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r <br /> opa�! man Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ETN <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd S urIrE� H <br /> �Q <br /> " !Well Permit Application E��V1jSE <br /> > 32 Now PERMIT ET XPIRES 1 YEAR FROM DATE ISSUED PERM <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 complianc an <br /> Joaquin County Development Title,Chapter 9-111 3 an, t �Str <br /> M,-t-;.2g <br /> n Joa n ounty Environmental Health Department. <br /> (WELL Location CroCity Zip��J Assessors <br /> y� Parcel# <br /> POwne ERT Address� s � l y� Zip Phone# <br /> 57 ontractor/-/6 Address ��t�# Myqone# <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW 1(VELL/BORING (CPT, OPROBE HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> OIL BORING# ---- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other not COPY GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC #TIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEalfllf ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: V <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XIUSH POINT GP CPT)GROUT SEAL PUMPED: 0 Y MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 0 0 (NOT <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ONDUCTOR CASING <br /> ROPO (if YES, list specifications in comment section) <br /> COMMENTS: x(� �Jl ( n Cl�"1 ^ <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 in accordance with San Joaquin <br /> County Ordinanc , Rules and R ulations, and all applicable California State Laws. <br /> Signedx_ Title/Company <br /> Print Name /iy( v� (,-( Date v5/� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 Z S H w y 9 2 / Y-" r6/2 f,i <br /> WORK PLAN DATED: Se b/ DD <br /> Application Accepted/By U Date Issued 70 Area <br /> Grout Inspection By Date Z,2 - -D Final Inspection ate /0- `4, 06 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: A ,zrncttJ oD D s -I - 2- B 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2�U 74- 1 /0/?�Zza� SR# 42 Dg <br /> C-57_ WC=WAIVER_ C-57 Letter of Authoriza ion o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />