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• <br /> q SAN JOAQUIN COUNTY <br /> JJ Ul/y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> y'. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> q .':N`P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s6gov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 compliance with San <br /> Joaquin County Dev o ment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> I 7 Svy��3" /�i9�/ G/t' D/i9//'�t17�/p Gi✓ Gu-bl qS-� UAssessorsO6 S 0�r�3 <br /> Well Location Cross Street City Zip/ V Parcel# <br /> Property C97_ U/I✓e/� <br /> Owner 17 <br /> _ Address q City UrvZipA/ Phone#1'09 p _ 3� 6 <br /> Contractor / r/lldress 9s� 11�/Y�G City �.��e//i✓Eip/y/ �-�_3, �t ���� Phone <br /> Cons ultant/&vb-entr_144-470T ft4 �ddress/'y� �'�P��4 'Ci � sr VA-01 I Phone Q* .`��3 `r�� <br /> *vp. <br /> GIS Coordinates:X 3��e Y l� s ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> JA WELL# PRESSURE GROUT <br /> *OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING NA IOLLOW STEM DIA.OF BOREHOLE // ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEELX PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL —&,f—_1r'TREMIE TYPE TO BE USED❑AUGERS9 HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 'Al&_�q /��/�/ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUC O S NG-2R SED (if YDS lyst�e�cifigt sin commgnt s�ectt <br /> COMMENTS: /l/�f✓ �ie��✓'D!�/�O-i 6 C, /i �rarc {y plc <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 appli tion and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California <br /> Signed A) Title/Company S;fr✓f/�u gQ��.✓ci Y ���P� of Pu��¢C <br /> Print Name f✓ /hf C/ /�C L Ci9��'OG L <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 11 1.),31,0 <br /> APPLICATION ACCEPTED BY c. <br /> /�f/ LJ� / � DATE ISSUED �d 22 AREA <br /> GROUT INSPECTION BY ��o <br /> mss? '� � FINAL INSPECTION BY /"�� ,&4DATE 4!011141 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> y17S 17 V <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />