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1 <br /> ;`. <br /> CID <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3plication 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 /> ,aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. f <br /> _ // �[ C _ Assessor's C/' a <br /> ELL Location�/�`K ✓n'Qrt> /v� -`uv/t. 0a C4r" of Cross Street Jv+..�Ase4tkt City jICJ�G Zip Parcel# <br /> 1.11 <br /> ROPERTY Owner ( /�, DT JTDC UYf Address <br /> n Ci y Zip Phone# <br /> 57 Contractor Illi vt Address/��L/ (�Lt1� /� City {1?wZ Zip C�Lic# Phone#225-319-58M <br /> onsultant/Sub Contractor(t1 Address/V f Y-&-tk t1�51 , City Lic# Phone#009-Z,3Y—D-'5W <br /> IS Coordinates:X _ Y Township Range Section <br /> IORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROBE, HYDROPUNC HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING /D 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> 3ther: Grout Specifications: <br /> OMMENTS �t� x Z8 � e � f !w/e atm SarwO��t� <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC []OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> ] 0 17 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Or ces, Rules and Regulations, and all applicable California State Laws. � <br /> Signed x J. Title/Company Du <br /> ?rintName ✓� /U�/r'� Date <br /> DEPARTMENT USE ONLY -- <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued C C =f,_ ZArea <br /> Grout Inspection By Date nal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDrrIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# E D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5 1 <br /> c� %Al ^ %A]Arvt r) /--F7 1 ottor of Authn I t10 o sign permit _ _ Encroachment doc 9/27/00 <br />