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r <br /> -s: a <br /> ORIGINAL <br /> Qi a!t!?y SAN JOAQUINt COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton,CA 95202-3029 IT CATION <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.s' cv.tac teh i ' <br /> WELL & BORING PERMIT APPLICATION <br /> AOR WILLS ANIJBORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ��� � ��� <br /> mON REFUNDABLE PERMIT EXPIRFS 1 YEAR FpnM DATE ISSUED Application is herebIlRQI1il1<tEAS( <br /> y made to San Joaquin Countyfor a permit tb construct and/or install the mik described. This application is triage in(eeflM <br /> Joaquin County Qevetopnrent Tittle.Ch{�apter 9-1115;3,and the Standards of the San Joaquin County Environmental Health Department. <br /> I Site Locail�n r.�'��7� t�7t'fi' lel i +. .� �t��2 <br /> .. . Crass:Sireet f i/I City Zip l APN.s -jLk!_ G <br /> Property r <br /> Owner U .....Address _ �6t`f City- ('z�t� <br /> C-67 Contractor.... i La.:. ,.,..Address r. v! City St. (' P LicJ 35 p l i <br /> Consuitaht)Bab:Cntr - Address 5'5'Zlil U <br /> Billable F'itrt Address Gii CK. ` �i <br /> GIS Goordlhetes:X V. <br /> !DONSTRUCTION WORK TO BE:PERFORMELI• <br /> (]NEW WELLIBORING:(CPT,GEOPRF7SE;:HYL)ROPUNCH,HAND AUGER,OTHER) <br /> Ej SOIL BORIIVG:IDs <br /> ©WELL IDs .. „.. <br /> TYPE&#CtF tELIiBO(d)NG INSTALLATION TY.0E CONSTRUCTION SAECIFICATIONS <br /> —0 MONITl7 Oov LOW STEM DIA:.OI=:BOREHOLE 0 MULTIPLE CASINGS©MULTI-LEVEL WELL CASINGOIA:.: <br /> _IO EXTRA CTKIN:Vapor]Wt"r-.. O HA. MLWDi7iV N CASING THICKNESS TYPF_OF CASING',CI STEEL O:PVC O OTHER: <br /> _(p SOIL VAPOR PROLE.: ) H1U�F2OTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O`AUGERS p HOSE O:P.IPE: <br /> ,..,_0 SOIL BORING rI FtUSg00INT(.P CPT)`. GROUT SEAL PiJMPED.(3 Yes E3 Noo(MAXIMUM FREEEALL DEPTRISI30TT) <br /> _t INJECTION(i e. c tp+.'$?ianel(]FiANL)Atl(aEFt; <br /> GROUT SPECIFICATIMS <br /> ( .OTHER: .: ❑OTHEfL' APPRCtX BORINCIEPTH ❑HQLTEd:T.FiAFFIC.8O)i. OR []STOVE:PIPE <br /> E.. <br /> CONDUCTOR CASING D No[I Yes:Casing Dla: Casiing beptti:.. Bamg"Oia ' <br /> COMMENTS: <br /> NOTE: ,OFFSITE WELLS&BORINGS REQUIREACCESSAGREEMENTS OR ENCROACHMENT PERMITS <br /> {}ESTRUCTION WORK TO BE PERF(}RMED, DE TRUCTION METHOD:LCHECK ALL THAiT APPLY <br /> #OF WELL(S)TO BE DESTRO :: OVER-Bt}RE DIAMETER OFf!INCHES TO DEPTH OFFT <br /> LL IDs: W J 7 E' Q PRESSURE GROUT TO DEPTH OF- FT BELOW SURFACE <br /> GROUT SPECIFICATIONS. 4f I C z" C i ❑EXPLOSIVES FROM ' To FT BELOW SURFACE <br /> TREMIE TYPE TO RE USED:El AUGERS.E HOSE PIPE. `A ©M SHROOM ATr,�3F ) <br /> _FT BELOW SURFACE <br /> COMMENTS .r <br /> 5 WORKING DAYS NOTICE REQUIREp(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENT'S <br /> i.hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> 14egulations,and all applicipple California laws. <br /> Signed TitielCompany ��U <br /> Pried Name {` I!► a i� ate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE DRESS <br /> WORK PLAN DATED o� <br /> APPLICATION ACCEPT 8 DATE K06 <br /> EA I <br /> GROUT INSPECTION • FINAL INSPECTION By TE <br /> DESTRUCTION INSPECTION BY <br /> r - _ <br /> COMMENTStCONDITIONS: : I,�(-�2 <br /> ACCOUNTING ONLY: A FAC# <br /> SERVICE RQ# <br /> PE CODES FEE INFO AMT REMITTED, CHECK# RECV'O By DATE INVOICE I <br /> REQUEST PR# <br /> $125 x / '� i /oG,:'a SR#COO& <br /> PR# f <br /> 2900 <br /> C_ 7 WC WAIVER4 -7.LETMER 0FAUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01 01113112 WELLPEwRMITAPP i <br /> I� <br /> 4.d <br />