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as SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> w:. ? 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone: (209)468-3449 F.Yx:(209)468-3433 Web:vww✓.sipov.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 vironmental Health Department. <br /> '/ Z Assessor's <br /> Well Location s tkt ,fid G e. Cross Street -� �ZBa�.�//uof%5�+,/�C � SG���7s• Zip �Z5i Parcel# <br /> Property �, <br /> Owner. Address tXYcw�o City T G Zip g5?d3 Phone <br /> p X77 <br /> C-57 Contractor �N P✓uh Address 110,�X 60-73 City Ori;nl�¢� C4# Lic#' ' 'a07 Phonc�309 S'gq-7cI If <br /> Consultant/Sub Cntr EatA�T"14R-&hAddress 6.5-3Ur^r t dig-# �3'�' City 5-,-.J. Licpt <br /> -�ant Phone M 172%2-y/4 3 <br /> GIS Coordinates:X Y Township Range Section <br /> WOOAK TO BE PERFORMED: <br /> ff NEW�W LIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> *0LIL BORING# p p-- D 6) D pT-7, Q�PT_�/PPT,-r0�P�i�l t/ �� 2- ❑AVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT ' 2�n.; <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2�it ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 14 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS P4 TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER V4 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL rn)_H ID/TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE P<PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes I(G No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑ ❑ <br /> BOLTED TRAFFIC BOX OR STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED �`' (if YES,list specifications in comment section) <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 applicable California Laws. <br /> Signed �,� Title/Company <br /> Print Name E)UV'2 ;"-q Date 6/- Ul—2-oy I <br /> Q�DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: W ' � <br /> WORK PLAN DATED: t' <br /> APPLICATION ACCEPTED BY DATE ISSUED 03/05 AREA I(' <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATEI Z " <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 /> l ( h SR#60j-41661 <br /> C 57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE IT ENCROACHM T DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />