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11/10/2005 15 59 2094583433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JQAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stoc UNIT 1V <br /> (209) 468-3449 ��T$' I'- 43 <br /> Application is herb NON-12E'FIJNDA81�PERMIT EXPIRES 1 YEJ : �'lil AUNTY <br /> y masse to San p L <br /> JOagenn County D"jopme i dke Jsaaqurn County for a Permit to construct and/or install the tie p7- p. pn is nide m compliance with San <br /> Pte'9-3 75 3 an the Stsridards of San Joaqulri Coua y Envfronrnerrtal F afth Department <br /> WELL•Location� � <br /> C_ "` 7Bi�t•�'�/ Cross Sti'ea: �y}�,. ssessors <br /> C ��,�y� Zp Cr9J33 <br /> PROPr; 441 vin fbv 1�iE(rrc ' �,Pame3# VrA" <br /> -11 <br /> Owner <br /> Address <br /> L Qty Zp Phone# <br /> C�7 Contractor fijfi Addr?s <br /> Phone# <br /> Consultant/Sub Cntr 4'l:r Address nn �X / �7 <br /> iJf, Cr —ALA' 1.1co Phone#��7�Pqe 6z <br /> GIS Coordinates �( ,�, <br /> Tp- —Range Section _ <br /> WORK T BE PE FORMFr) - <br /> �dEW WELL 1 BORING (C7 GEOPROSE,HYDROPUNC.4.HAND-AUGER,OTHER') <br /> 7IAMETOIL BORNG a DESTRUCTION (d0ase type below) <br /> a WI=LL# OVER-BORE <br /> [I*Other Q PRESSURE GROUT <br /> SPECIFICATIONS GROUT <br /> COMMENTS <br /> TYPE OF WELL IN -LATION TYpE CONSTRUCTION 4ZPECIFI1-A7 ONS <br /> [I Iti+ONITCRlNG [I HOLLOW S71=M DIA OFBOREHOLI;S" <br /> 0 MULTIPLE CASINGS 9 MULTI-LEVEL WELL CASING DIA. <br /> ACTION ©AIR H MMEPJDRIVEN CASING THICKN SS TYPE OF CASING <br /> 9 VAPOR MUD PUMPED ROTARYLpfy+t�y DEPTH OF GF�OUT SEAL 11 STEEL, 11 PVC 0 OTHER_ <br /> aAfR SPARGE/OZONE [[PUSH-1 POINT(GP or11CA'I)G,ROLiT SEALSEPUMPEDY� jj N TREMiI�TYPE TO BE USED Q AUGERS �gOSE� <br /> �SpIL BORING IY HANO AUGER v (NOTE MAXI UM FREE-FALL DEPTH IS 3Q'} <br /> GROU7SPECIFICATIDNS <br /> II OTHI?A (pr f0 <br /> OTHER��......�._ AIaPR4X BORING pEl7TFi_1.4�S_ <br /> []BOLTEC)TRAFFIC BOX or rI STOVE PIPE <br /> ti COhIDU�TOfR CASING PROR SED VLV (if YES,list SpeciflGaUprts in cornm2rit section) <br /> COMMENTS }�� S <br /> a► i c+�i�r`C <br /> NOTE- OFFSITE ORIh! S REQUIRE ACCESS AGREEIUIE ! OR EN QACNMENT PERMITS. <br /> 48 WORRfNG HOU <br /> r <br /> I hereby certify that I have repared then application and that the work will be done in accordance with San JOagUln i <br /> County Ordin ons, and all applicable California State Laws. <br /> Signed x y <br /> �+� Tile/Company <br />'nnt Name <br /> DEPARTjiAENT USE DN_LY <br /> Date Q <br />'aITE MAP IN UNIT IV!FILE, ADDRESS. Pe.tj <br /> NORK FLAN DATED: <br /> n Accepted B <br />;rout Inspection <br /> Dato Issued /D <br /> Date V J pies f�f�J <br /> gout nspp Date sy ate <br /> Final Inspection By <br /> iestnictran Inspection By <br /> Date <br /> OS 1 CONDITIONS <br /> EACCOIVNTINIGjONLY Alli# FAC#INFO AMOUNTREMrrTED <br /> CHECK-""'( <br /> RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> � � <br />