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Saar Joaquin County <br /> nvironmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, C,A 9520� D})ft" C' _� GA�' O <br /> (209)4E;8-3449 Fax: (209)468-3433 Web: ww�v.sjgov.or }it3 � �I1�r ITS <br /> t r <br /> i <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 1 fC #id1 iae�iolcompliance with Sant <br /> Joaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County Environment l $h&E � <br /> �_,.i �A�sessars l <br /> WELL Locatlon ' 1 e r§ go Gross Street City rd Zip �6-�0 Parcel# <br /> PROPERTY <br /> C)wne€' 44��,,� l 330 Phone#S _! r ZGS <br /> C-57Contractor Address 0-' <br /> CiteSIe�h Zi `k564 y p Lic#�7-0��Phone# <br /> Consultant/Stab Cott Address 7cOs0 $ 7— --_City Try G Lic# Phone# QZA� tT 35 06 l0 <br /> GIS Coordinates.X Y Township Range_ Section <br /> WORK TO BE PERFORMED: <br /> P(NEW VVELL I E30RING (CPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# aOVER-BORE. DIAMETER <br /> ELL# r r ©PRESSURE GROUT <br /> or- <br /> °OtU GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INS3>4LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF B0REH0LE_LU_ D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA: <br /> 0 EXTRACTION a AIR FAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL -]('PVC ® OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE U D; Q AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SDIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: q OTHER_,____ APPROX,BORING DEPTH U BOLTED TRAFFIC BOX or 0 STOVE FiPE <br /> CONDUCTOR CASING PROPOSED (if YES,iist specifeations 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 in accordance with San Joaquin <br /> County qvAnances, PWes and Regulations, and all applicable California State Laws. <br /> Signed x s%ti_, xver -11 _Title/Cornpany <br /> Print Narna Z.� �G a t� _ Date <br /> DEPARTMENT USE ONLY <br /> s `\ <br /> SITE MAP IN UNIT 1V FILE, ADDRESS: l��5f � A'r'� <br /> WORK PLAN DATED: <br /> f <br /> Application Accepted By _ Dale Issued Area.„��Groat Irispectirn BY _ Date --Final Inspection By_ ��. Date <br /> Destruction Inspec#ion By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC`D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> mm � <br /> C-57_ WC__-WAIVER C 57 Letter of Authorization to signerrirlt�_ En crogc�tment doc <br /> I::lll)2 9 44 2-00 1 <br /> _ t,/�2rtla <br />