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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> t t 600 East Main Strget, Stockton, CA 95202-3029 MITIGATION <br /> ' Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.s'gov.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 1 ment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �` 1 �'`� Assessor's <br /> s <br /> Well Location r,� S �✓( Cross Street 4_),4ev Cl�x v.� city Glx ZipParcel# <br /> Property <br /> Owner CI o Address G ! City k L t. Zip .g10.TW_i Phone# A@!(ZCq)q3'7_$381 <br /> C-57 Contractor EN p✓t,� Address iP�d. x X093 City QvxvMt$C4 Lic#pry` � Phon'&3G)5Qq'Z0I,7 <br /> Consultant/Sub Cntr E4v4,--'T 4E:?cNAddress 65V tJ�i✓us�ax �''ZfS City Lic#����Phon��>S}�12 y"y/y 3 <br /> GIS Coordinates:X ,Y Township Range Section <br /> W,O_RK TO BE PERFORMED: <br /> L�JNEW W LL/BORING(CPT GEOPROB ,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING#1� r(2P/'� ❑O ER-BORE DIAMETER <br /> ❑WELL# �RESSURE GROUT �]�e•-qtr <br /> F1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A1 TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER A 24 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL ,! OrREMIE TYPE TO BE USED El AUGERS[�}'1'iOSE <br /> El AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes 09' o (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 9SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH / ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 2 Lam_ Title/Company <br /> Print Name C'&LLvd 13UV7 <br /> Date <br /> �DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: 1-00 <br /> 4/— 'mWORK PLAN DATED:APPLICATION ACCEPTED BDATE ISSUED AREA Cr <br /> GROUT INSPECTION BY I�LCAA� FINAL INSPECTION BY DATE f <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> '0 �� e. I 13 I SR#WS 6L 7 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />