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NA <br />WELL PERMIT APPLICATION FORM V,f L <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 9-111!5.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Locationzsy0 �. ��-a r••io�1 Cross Street r % � s4 �-� Assessors <br />City oc.. c•, Zip'75 Z-o,'S Parcel# N3' <br />PROPERTY / q <br />Owner �1c� ��n Address' s 23 Sa , V , r o,CL dCity_�I . Zip 1 S Z. c� Phone# /V <br />C-57 Contractorr-cgr. :4 c.. Address 2S [7 of c e R,City/"t ; ntL Zip cY55? Lic#��SC�{�- Phone# f �-5 <br />Consultant / Sub Cntr l-'��6�;0. Address z'_i='a.rkl.tS $4, City�Lic#j�,Z" 4Phone# 50 <br />GIS Coordinates: <br />Y <br />Township <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) <br />[I SOIL BORING # Z 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />O'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N f TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I So TREMIE TYPE TO BE USED: 0 AUGERS -U HOSE <br />0 AIR SPARGE/ OZONE -B PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 'Q Yes 0 /No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />jJ SOIL BORING O HAND AUGER GROUT SPECIFICATIONS �F-'t i4,.( co -T' tea. n4 ]� <br />0 OTHER: fI OTHER APPROX. BORING DEPTH 150 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED A (if YES, list specifications in comment section) <br />COMMENTS: CFS or: nc J�-Z t r rti� c���Of <br />NOTE: OFFSITE B RINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State/Laws. / ^� <br />Signed Q Title/Company <br />Print Name GCS -7=n qT$nr--,: n 4 Date <br />DEPARTMENT USE ONLY Q <br />SITE MAP IN UNIT IV FILE, ADDRESS: �� 6en•- c/L tiTZ WORK PLAN PLAN DATED: ?---x <br />Application Accepted <br />Date Issued /P r! V -6 q Area e,6 <br />Grout Inspection By Date Final Inspection By <br />Destruction I <br />COMMENTS / CONDITIONS: <br />Date <br />V�� <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />35o <br />645 <br />�' <br />I`�C)s <br />6_� _ot <br />SR# cot -.3 <br />C-57 V WC V -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />