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E E V <br /> San Joaquin County <br /> pl_ <br /> Pro 1 "Vironmental Health Department SITE <br /> 304 �r Avenue, 3rd Floor, Stockton, CA 95202 MITIC_eYIn✓ 1 <br /> • • E�l1MR <br /> ax: (209)46$ <br /> � � -3433 Web: www.sjgov.org/ehd <br /> P G <br /> �' Well Permit Application — <br /> NON-REFUNDABLE <br /> 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 applicat �`� '� Ian <br /> Joaquin County Development Title,Chap ter <br /> �9-111115,3 and the Standards of San Joaquin County Environmental Health Dep <br /> WELL Locatlon/ G0�S�✓ �(„�y r" Cross Sirae 0`� �` Zipj <br /> PROPERTY �y�+, G' <br /> Owner C� Address 6 j ' / _ ity -Zip/oViJ Phor <br /> C-57 Contractor _S G�//= // Address L LIY' Cfty _C Zip� c#_ <br /> Consultant 1 Sub Cnt"/ �" Address �� rL� Ci Lic# Phone# <br /> GIs Coordinates;X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )MEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER.) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORINr 0 OVER-BORE. DIAMETER <br /> )NW ELL# �` I� f 0 PRESSURE GROUT <br /> 0 Other ' f f ` GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> VMONITORING '"OLLOW STEM DIA.OF BOREHOLE/J�'0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 154 '5� d TYPE OF CASING: 0 STEEL�PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ! Z) TREMIE TYPE TO BE USED: ,'AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0-Yes /VNo ((NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> J]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS _-,� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH �XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) j <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 in accordance with San Joaquin <br /> County Ordinances, Rules an gulations, and all applicable California State Laws. <br /> Signed x / Titlelcompany <br /> Print Name ✓IZ42 S Date <br /> r•� 5 DEPARTMENT UE ONL.Y, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I�7 • <br /> WORK PLAN DATED: OV <br /> Application Accepted By Date Issued S-r 3'O / Area!6 i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY; AlD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z S R# 66 J'� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6122/04 <br />