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a 'k • an Joaquin Count <br /> �:'moi•--o D <br /> ECH mental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> JU(209)f5jM9 Fax: (209)468-3433 Web: wwwsjgov.org/ehd UNIT IV <br /> �4t!FORN`P ENVIRONMENT HE"II Permit Application <br /> PERM'16V& 16,,BLE PERMIT EXPIRES t 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, <br /> Chapter 9-1111.3 andg S ,ndar/1s of San Joaquin County Environmental Health Department. <br /> WELL Location h 15" red(J �� ` 7 DI (.{GI p� /� �,,.eel <br /> (�5'7C3Assessors <br /> Cross Street�• I�v'`-MGiCity (n ip ( w`JParcel# <br /> PROPERTY //-- p <br /> Owner fF/ ddress 3q5'N U re/o`�city�Ck � <br /> ZipZPhone# I <br /> C-57 Contractor T)117� '/�G Addressl,�V 111/b/t0e_ 22.' Clty.� 747 Zip��3Liae��/6Shone#.�/C/`f'Z5)3�(3p-S j7 <br /> Consultant/Sub Cntr /U ��4M'e /16R Address l�f'1 t-!�j/'tO� �Cty Lic# /y'� Phone# elfJ-)�r�c— <br /> 04.500 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,ANEW WELL/BORING (CP GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) p DESTRUCTION (choose type below) <br /> ,$SOIL BORING# 1 a OVER-BORE. DIAMETER <br /> jrWELL# — n PRESSURE GROUT <br /> 0•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE/L1`0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS JC O TYPE OF CASING: n STEEL ALPVC n OTHER: <br /> 0 VAPOR if MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: %kYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 4SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER:_0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COnNDUCTOR CAS <br /> (50dN`G PROPOSED -11C' (if YES,list specifications in comment section) <br /> COMMENTS: l,t/I/1 ��-Q `i�/ `��r � 0d 9Cf`I271) <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 and Re uI tions nd all applicable California State Laws. <br /> Signed x �'�� . V��///gyp. :� �i Title/Company -L ) e(Y- <br /> Print Name l i �Yi(� � �`��Z. 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By G Date Final Inspection t/ Date <br /> Destruction Inspection Dale /ooF o 0 <br /> COMMENTS I CONDITIONS: ,1'-F O ),r O ./0( { <br /> ACCOUNTING ONLY: AID# Y4/ M FAN Sw NI r e' p £H <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2.Q01 89 .00 1408 �/,L �4(v SR# 4 39:j <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />