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:.� _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Y_@ephone: (209) 468-3449 Fax: (209)468-3433 Web:www.sigov.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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> Zip Parcel#Weli Location Cross Street *d"f x City <br /> �.t 7 <br /> Property- tt r i <br /> Owner :Address City - Zip Phone# <br /> r CityAdress PhoneC-57 Contractor � o 'i C <br /> — " <br /> Consultant/Sub Cntr 1 Address 3Yt-r'" City r- ,"` Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW ELL/BORING(CPT OPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ''a ❑OVER-BORE DIAMETER <br /> ❑WELL# `' ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE eZ, de ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA,��� <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER S <br /> El VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL if-1710C TREMIE TYPE TO BE USED❑AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE tJ PUSH POINT(GP OR CPT)t GROUT SEAL PUMPED:❑Yes E]No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ff'OTHER: C04'�Y ❑OTHER: APPROX.BORING DEPTH S / ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> i C NDUCTOR CASING PROPO ED (ifk YES,list specifications in comment <br /> COMMENTS: t`� 6 l( r '°" i 1 t G Gmak^•- 1 4 .1 1 `Inll r2 ltion <br /> t� <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 application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap lica Is California Laws. <br /> Signed T Title/Company tCFS ' ^,t}' <br /> E <br /> Print Name �� b '� - DateI <br /> D DEPARTMENT USE ONLY Q _ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �- <br /> WORK PLAN DATED: CU P-(A-'(S1CW <br /> APPLICATION ACCEPTED BY DATE ISSUED f t` 24/6? AREA'7'7Z <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY (J, ,- I DATE <br /> COMMENTS/CONDITIONS: GLe,U lzC./ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> dq0 1�`2- GCS-6t 44- 11 121 0,k SR# �S <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115/07(WEB) WELL PERMIT APP <br />