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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 PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,oplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> X11 I, \ '\n p Assessor's <br /> YELL Loeati n 1'l • VV1�- pp,,yy��Cross Street II\t .City YT' 1 Zip.qL Parcel# ibl-4'�11t�-ID <br /> 'ROPE RTY ner l ro S �Addras i I Cit>�Q�(i�.��115n� zip"_4jbaPhoneojrD- 4 --q(D5� <br /> ;•57 Contracto Addressr'f0DOWO—eee, ��� Ci ZiPJ�` --Lic#jjjVj(1Phone#//'11•il�-(R��v�I:JD- II � <br /> :onsultant/Sub Contracto Address bye, City[�(e..Lic# PhoneAIh-QDI-b'4n <br /> ;IS Coordinates:X ,Y - ,Township Range Section <br /> VORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> (NEW WELL/BORING(CPT,�EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p OVER-BORE <br /> $„SOIL BORING# -1 <br /> D WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> :OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING HOLLOW STEM DIA.OF BOREHOLE l r MULTIPLE CASINGS?0 YESNO WELL CASING DIA: <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> ]VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:GAUGERS D HOSE <br /> ]AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:XY D No (NOTE; npAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: OlD k ClA—II 'Iii. A0 - "( <br /> ]OTHER: n OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? D (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> Coun40rances, RUI d Regulations, and all applicable California State Laaws..TIUe/Companysfi�caned Print N2. 1 Date <br /> DEPARTM NT USE ONLY <br /> �I LE Co P�1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 -+`t 7 W-e2ft-rpt L d <br /> WORK PLAN DATED: 31 l t� D"'� <br /> Application Accepted B Date Issued / O Area <br /> Grout Inspection By y �-d-1 J: —Date '> ` r'_ Final Inspection By _ _ Date '' t`'!' <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS* <br /> ACCOUNTING ONLY: AID# terve <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST i INVOICE <br /> A9ol $$y,00 <,gIA54 l' r 3lN o SR# 33 0 � <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />